THE SIGNIFICANCE OF THE PSYCHOSOCIAL WORK … Publication... · 2016-05-25 · the significance of the psychosocial work environment for care workers`perceived health, presenteeism,

THE SIGNIFICANCE OF THE PSYCHOSOCIAL WORK

ENVIRONMENT FOR CARE WORKERS`PERCEIVED HEALTH,

PRESENTEEISM, RATIONING OF CARE, AND JOB

SATISFACTION: A SUB-STUDY OF THE SWISS NURSING HOME

HUMAN RESOURCES PROJECT (SHURP)

INAUGURALDISSERTATION

zur

Erlangung der Würde eines Dr. sc. med.

vorgelegt der

Medizinischen Fakultät der Universität Basel

von

Suzanne R. Dhaini aus Libanon / Kanada

Basel, 2016

Original document stored on the publication server of the University of Basel edoc.unibas.ch

This work is licensed under a Creative Commons Attribution-NonCommercial NoDerivatives

4.0 International License

2

Genehmigt von der Medizinischen Fakultät

auf Antrag von:

Fakultätsverantwortliche Prof. Dr. S. De Geest

Dissertationsleitung PD Dr. R. Schwendimann

Co-Referat Prof. Dr. M. Simon

Externes Referat Prof. Dr. R. Kunz

Externes Referat Prof. Dr. A. Matthews

Basel, den 14. März, 2016

Dekan Prof. Dr. med. T. Gasser

3

LIST OF ABBREVIATIONS

ADL Activities of Daily Living

BBF Blood and Body Fluid

BERNCA-NH Basel Extent of Rationing of Nursing Care - Nursing Home Version

β Beta Coefficient

CNA Certified Nursing Assistant

COBB Fragebogen zur Erfassung von affektiven, kalkulatorischem und

normativem, Commitment`gegenüber der Organisation, dem Beruf/der

Tätigkeit und der Beschäftigungsform

CI Confidence Interval

DRG Diagnostic Related Group

EU-OSHA European Agency for Safety and Health at Work

GEE Generalized estimation equations

HPSI health Professions Stress Inventory

I-CVI Item Content Validity Index

IOM Institute of Medicine

LPN Licensed Practical Nurse

MBI Maslach Burnout Inventory

NA Nurse Aide

OR Odds Ratio

OSHA Occupational Safety and Health Administration

PES-NWI Practice Environment Scale-Nursing Work Index

RN Registered Nurse

SAQ Safety Attitude Questionnaire

S-CVI Scale Content Validity Index

SHURP Swiss Nursing Home Human Resources Project

WHO World Health Organization

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TABLE OF CONTENTS

ACKNOWLEDGEMENTS 7

PREFACE 9

SUMMARY 10 REFERENCES 14

CHAPTER 1 INTRODUCTION 16 1.1 WORK RELATED HEALTH AMONG CARE WORKERS: THE MAGNITUDE OF THE PROBLEM 18 1.2 PRESENTEEISM: AN EMERGING PROBLEM 20 1.3 DETERMINANTS OF WORK-RELATED HEALTH AND PRESENTEEISM 21 1.4 EFFECT OF HEALTH AND PRESENTEEISM ON RATIONING OF CARE 24 1.5 THE EFFECT OF WORK ENVIRONMENT AND HEALTH ON JOB SATISFACTION 24 1.6 THE WHO MODEL FOR HEALTHY WORKPLACE 25 1.7 IDENTIFIED RESEARCH GAPS AND DISSERTATION RATIONALES 27 1.8 STUDY AIMS 29 1.9 REFERENCES 30

CHAPTER 2 CARE WORKERS HEALTH IN SWISS NURSING HOMES AND ITS ASSOCIATION WITH PSYCHOSOCIAL WORK ENVIRONMENT 38 2.1 ABSTRACT 39 2.2 INTRODUCTION 40 2.3 CONCEPTUAL FRAMEWORK 41 2.4 METHODS 43 2.5 RESULTS 47 2.6 DISCUSSION 57 2.7 STRENGTHS AND LIMITATIONS 59 2.7 CONCLUSIONS 59 2.8 FUNDING/ POTENTIAL COMPETING INTERESTS 60 2.9 ACKNOWLEDGEMENTS 60 2.10 REFERENCES 61

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CHAPTER 3 ABSENTEEISM AND PRESENTEEISM AMONG CARE WORKERS IN SWISS NURSING HOMES & THEIR ASSOCIATION WITH PSYCHOSOCIAL WORK ENVIRONMENT: A MULTISITE CROSS-SECTIONAL STUDY 65 3.1 ABSTRACT 66 3.2 INTRODUCTION 67 3.3 THEORETICAL BACKGROUND 68 3.4 METHODS 71 3.5. RESULTS 76 3.6 DISCUSSION 83 3.7 STRENGTHS AND LIMITATIONS 84 3.8 CONCLUSION 85 3.9 FUND/CONFLICT OF INTEREST 85 3.10 ACKNOWLEDGEMENTS 85 3.11 REFERENCES 86

CHAPTER 4 CARE WORKERS` HEALTH, PRESENTEEISM, AND IMPLICIT RATIONING OF CARE IN NURSING HOMES: A MULTISITE CROSS-SECTIONAL STUDY 89 4.1 ABSTRACT 90 4.2 BACKGROUND 91 4.3 METHODS 94 4.4 ETHICAL APPROVAL 97 4.5 RESULTS 97 4.6 DISCUSSION 105 4.7 STRENGTHS AND LIMITATIONS 106 4.8 CONCLUSION AND IMPLICATION FOR NURSING MANAGEMENT 106 4.9 REFERENCES 107

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CHAPTER 5 FACTORS ASSOCIATED WITH JOB SATISFACTION AMONG CARE WORKERS IN SWISS NURSING HOMES ---A CROSS SECTIONAL STUDY 110 5.1 ABSTRACT 111 5.2 BACKGROUND 112 5.3 METHODS 114 5.4 RESULTS 120 5.5 DISCUSSION 125 5.6 STRENGTHS AND LIMITATIONS 127 5.7 CONCLUSIONS 127 5.8 ETHICS APPROVAL 128 5.9 COMPETING INTERESTS 128 5.10 FUNDING 128 5.11 AUTHORS’ CONTRIBUTIONS 128 5.12 ACKNOWLEDGEMENTS 128 5.13 REFERENCES 129

CHAPTER 6 SYNTHSIS AND DISCUSSION 133 6.1 SYNTHESIS OF KEY FINDINGS 134 6.2 DISCUSSION OF KEY FINDINGS 135 6.3 THEORETICAL BACKGROUND, CONCEPTUALIZATION AND MEASUREMENTS OF CARE WORKERS`

HEALTH 139 6.4 STRENGTHS AND LIMITATIONS OF METHODS 141 6.5 IMPLICATIONS FOR PRACTICE 142 6.6 IMPLICATIONS FOR FUTURE RESEARCH 144 6.7 CONCLUSIONS 145 6.8 REFERENCES 147

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ACKNOWLEDGEMENTS

For the last couple of years I have been planning the day I will pen my acknowledgements

and pour out my soul, but now that the moment has come, I find myself blank.... Though only my

name appears on the cover of this dissertation, a great many people have contributed to its

production. It was the end result of a long and tedious process encompassing sedulity,

disappointments, joy, and a conducive learning environment, full of encounters with real mentors,

who were the crowning achievers of my success. I owe my gratitude to all those who have made this

dissertation possible and because of whom my PhD experience has been one that I will cherish

forever.

First and foremost, I would like to thank the four members of my PhD Committee. A sincere

thankfulness goes to my advisor, Dr. René Schwendimann for his wisdom and guidance. I have been

amazingly fortunate to have an advisor who gave me the freedom to explore on my own and at my

own pace, and at the same time the guidance to recover when my steps faltered. His patience,

support, encouragement, and flexibility helped me overcome many crisis situations and finish this

dissertation. I am also thankful to him for carefully reading and commenting on countless revisions of

all my manuscripts. He is a real mentor.

I would like to extend my greatest appreciation to my co-advisor, Prof. Dr. Michael Simon,

who kept a sense of humor when I had lost mine. With his open door policy, he has been always

there to listen, to answer my late night emails about perplexing statistical tools and results, and to

give advice. I am also thankful for enforcing strict validations for each research result, and thus

teaching me how to do research. I am deeply thankful!

My motivation to contribute to the research of health of the nursing workforce is derived from

their dedication and passion for nursing research, where our meetings had always been rich with

fruitful discussions, reflections, and lots of encouragements. They provided the basis of my

professional growth.

I would like to express my heartfelt gratitude to Prof. Dr. Sabina De Geest, who believed in

me and opened the doors wide for me to come to Basel and to prove to myself, and the rest, that I

could succeed! Her insightful comments at different stages of my research were thought provoking

and they helped me focus my ideas. I am grateful to her for holding me to a high research standard.

Her maddening astuteness and attention to details drove me to finally learn to think broader and

become the researcher I have become today.

I also gratefully acknowledge the limitless support of Dr. Regina Kunz for her numerous

revisions of my manuscripts and valuable comments, which helped me improve my knowledge on

related topics.

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Special thanks go to Prof. Dr. Sandra Engberg, who provided highly appreciated feedback on

the conceptualization and development of the papers in the early phase of this dissertation.

I offer my deep appreciation to the SHURP team Dr. Franziska Zuniga and Dr. Dietmar

Ausserhofer, in addition to Kris Denhaerynck, from whom I benefited tremendously through

collaboration and discussion of pressing and arising questions.

I also appreciate the other types of support I have received throughout this process. Fulfilling

successfully all steps of the dissertation would have been impossible without colleagues who

acknowledged the challenges of this tiresome process. Hence, i thank all members of the Institute of

Nursing Science (INS) at the University of Basel, particularly the A-team (Greet Van Malderen,

Branda Marcus, Klara Remund, Cornelia Kern, and Michael Huber), whose impeccable

administrative support facilitated my life at the institute in countless ways. I would also like to thank

all PhD fellow peers, especially Sonja Beckmann who escorted me on the train routinely, back and

forth to Basel and Zurich, recognizing my daily challenges.

Further, I dedicate this dissertation to my family, who offered me other types of support. To

my mom, whose constant and unwavering encouragement and prayers, and her willingness to look

after my children in the last four years, made this possible! To my dearest husband, who offered me

unconditional love and support to fulfill my dream, and made an extensive effort listening and helping

me pull through. To my precious ones, Jad and Chloé, I am sorry for being away from you many

mornings and countless evenings, but I am sure that one day you will grow and understand that you

should be proud of your mom.

Most importantly, a very special thanks goes to God for giving me the strength, and for

creating a splendid universe available to be studied!

Suzanne R. Dhaini, February 1st, 2016

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PREFACE

This dissertation thesis is imbedded in the multicenter cross-sectional Swiss Nursing Homes

Human Resources Project (SHURP) using care workers and organizational survey data. SHURP is a

research project that proposed to bring a better understanding of the structural and organizational

conditions, care workers characteristics, and that of residents, in the Swiss nursing homes. The

SHURP project with focus on institutional long-term care is in the tradition of nurse outcomes studies

such as the international Nurse Forecasting: Human Resources Planning in Nursing (RN4CAST)

project. SHURP was led by the Institute of Nursing Science (INS) at the University of Basel and has

focused on care workers in Swiss nursing homes.

The demographic development of Switzerland, with high life expectancy and a growing

number of older people, will increase future demands for support and care services. It is projected

that the number of elderly placed in nursing homes will further increase {Bayer-Oglesby L, 2010

#269}. So far, research in the last decade was devoted to the field of institutional care with different

issues such as quality of care, work environment, and costs. Despite existing studies, the complex

relationships and interactions between these different factors that determine ultimately the quality of

care in nursing homes have not been studied comprehensively, particularly in Switzerland.

Of the 1,600 nursing homes across Switzerland, a representative sample of 163 nursing

homes stratified according to the German, French, and Italian speaking regions and facility size have

participated in the SHURP study conducted from 2011-2013 by the University of Basel’s Institute of

Nursing Science. To date, SHURP represents one of the largest nursing home workforce studies

conducted in Switzerland, and internationally. It helped to gain an extended knowledge of the

relationships between organizational structures, profiles of institutions, characteristics of care

workers, and resident outcomes, to respond to pressing questions in long-term care.

By care worker surveys, as well as nursing home administrative and resident data, the

SHURP team assembled and analysed data on a set of care worker-related organizational factors,

including work environment (e.g. leadership, staffing adequacy, collaboration, workload, work

stressors), care worker characteristics (e.g. educational level, professional nursing experience), self-

reported care workers` outcomes (e.g. presenteeism, absenteeism, work related health, job

satisfaction), perceived rationing of care, and residents outcomes (e.g. adverse events,

hospitalizations), in addition to organizational characteristics (e.g. ownership status, staffing,

occupancy rate). The resulting data enables modelling of work environment aspects to analyse how

modifications might promote safety at the workplace in order to improve care workers outcomes and

help meeting residents’ needs through ensuring the provision of appropriate care. Subsequent

studies not only enabled this dissertation project, but also added value to the SHURP project, as it

allowed us to illuminate this important issue on a national level for the first time.

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SUMMARY

Healthcare is a high-risk industry, not only for patients, but also for staff, whose health and

wellbeing can be affected. While research has extensively examined the health of care workers in

hospital settings [1-3], nursing homes have been less researched in this regard. Nursing homes are

an important sector of the care system that is becoming increasingly complex with the growing

elderly population. In Switzerland, with the introduction of Diagnostic Related Group (DRG) with

reduced length of hospital stay and accelerated patient discharge [4], nursing homes are delivering

more sub-acute care to residents with complex medical conditions. More than half of residents in

Swiss nursing homes are diagnosed with dementia or show signs of dementia, and require

assistance to meet basic needs in activities of daily living [5]. Consequently, nursing home care

workers often perform nursing activities such as patient handling and positioning, and communicating

with challenging residents that put them at risk of physical injuries and compromised mental health. A

particular concern is presenteeism, which refers to attending to work while ill, and which showed to

be common among care workers [6].

Workplace environments in health care settings have shown to be with risks for staff health,

e.g. for musculoskeletal injuries [7] and needle stick injuries [8]. Researchers also found increased

rates of emotional exhaustion [9] and musculoskeletal pain among direct care providers [10]. Job

demands at work were found strong factors in contributing to increased injury rates [11]. Mental

health outcomes were positively influenced by social support at work [9]. While the magnitude of the

problem of care workers working through illness and its ramification on the provision of care in

nursing homes has not been fully identified so far, researchers recognize its effect on the quality of

care [12].

This dissertation aims to explore care workers` reported physical and mental health in Swiss

nursing homes, analysed relationships with contributing factors (e.g. psychosocial work environment

factors) and outcomes (e.g. rationing of residents care and job satisfaction) in four studies. These

studies analyse data from the Swiss Nursing Homes Human Resource Project (SHURP), including

survey responses from a survey of 5,323 care workers in 162 Swiss nursing homes, across the three

language speaking regions (German, French, and Italian) [13].

The dissertation is organized in six chapters:

Chapter 1 is an overall literature-based introduction to the topic. It explores the association

of the work environment and care worker’s health. Emphasis is placed on nursing home care

workers, and the importance of their perception of work environment factors, including, but not limited

to, leadership, staffing adequacy, work stressors, and autonomy at work, and how they influence

care workers related behaviour (e.g. presenteeism, absenteeism). The influence of care workers`

health on rationing of care, and the relationship between health and work environment with care

11

workers` job satisfaction, are also discussed. An overview of the state of research on care workers`

health in nursing homes and the conceptual framework of this dissertation is presented. In the final

part of the introduction, gaps in the literature are summarized, along with the contribution of this

dissertation to address those gaps. Aims and rationale of the dissertation are described. Findings

addressed in four component studies are reported (Chapter 2 to Chapter 5).

Chapter 2 reports on our study describing care workers` perceived health, exploring

relationships between selected perceived work environment factors and self-reported physical and

mental health outcomes. In this sample of 3,471 care workers from 155 nursing homes across

Switzerland, 38% reported at least one compromised physical health outcome, and 27.4% reported

at least one mental health outcome. Back pain (19.0 %, n=655), and joint pain (13.5%, n=464) were

reported physical health outcomes. Emotional exhaustion (24.2%, n=834), tiredness (14.4%, n=494),

sleeplessness (12.6%, n=432) were the most prevalent self-reported mental health outcomes. After

controlling for major organizational variables and care workers` characteristics, percentage of

residents with dementia, physical violence and participation in decision-making were not predictors of

health outcomes in our regression models. However, back pain and joint pain were associated with

increased workload, conflict with other professionals and lack of recognition, frequent verbal

aggression by residents, and perceived poor staffing adequacy. Sleeplessness, tiredness, headache,

and emotional exhaustion from work, were associated with stress related to increased workload and

conflict with other professionals and lack of recognition. Perceptions of strong leadership were

associated with low-reported emotional exhaustion. Overall, our findings confirmed that poor

psychosocial work environmental factors in nursing homes were related to the perceived physical

and mental health of care workers. Modifying psychosocial work environment factors in Swiss

nursing homes is a promising strategy to improve the health of their staff.

Chapter 3 presents the results of our explorative study of the prevalence of presenteeism

and absenteeism in Swiss nursing homes, and their associations with care worker-reported selected

psychosocial work environment factors. Of the studied 3,176 care workers in 162 nursing homes,

prevalence of presenteeism (32.9%) was higher than absenteeism (14.6%). Although self-reported

absenteeism showed no significant association with any of the psychosocial work environment

factors investigated in this study, low reported presenteeism was associated with perceptions of

supportive leadership (OR 1.22, CI 1.01-1.48), and adequate staffing resources (OR 1.18, CI 1.02-

1.38) only. The findings suggest that presenteeism is an area that has been overlooked in nursing

homes. Hence, it is reasonable to focus on presenteeism in order to promote care workers` health

and to promote productivity and sustain the organization. Future analysis is needed to investigate the

influence of presenteeism on the provision of residents care.

Chapter 4 presents study findings on the association between care workers-reported health,

presenteeism and perceived implicit rationing of care. Studies showed that the exposure to an

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unhealthy workplace can compromise care workers physical and mental health. As the WHO Model

for Healthy Workplace suggests, ill employees who work through illness have reduced work

performance. Work performance can be assessed through omission rates in relation to required

tasks. Care providers often reported implicit rationing of care (i.e. omission of care) due to various

limitations. Of the 3,239 participating care workers in 162 nursing homes, physical and mental health

issues, and presenteeism were of concern, and rationing of care was reported as rare. Our findings

give support to the sensitivity of rationing of care to health issues: For rationing of activities of daily

living, our regression model showed a positive association with perceived health: joint pain (β 0.04,

CI 0.001-0.07), emotional exhaustion (β 0.11, CI 0.07-0.15), and presenteeism (β 0.05, CI 0.004-

0.09). For rationing of caring, rehabilitation, and monitoring, results were similar: joint pain (β 0.05, CI

0.01-0.09), and emotional exhaustion (β 0.2, CI 1.16-0.24). Health organizations should be aware of

health-related issues at the workplace to promote and maintain care workers` health, in order to

ensure resident safety and appropriate provision of care. Further observational studies are needed to

gain a deeper understanding of the individual decision of care workers for presenteeism and its’

impact on work performance, which may ultimately impact quality of care.

Chapter 5 presents major findings on care workers` job satisfaction and its association with

work environment factors and perceived health. Recruiting and retaining care workers to meet the

challenges of a growing elder population are connected to the satisfaction of care workers in the

workplace. The conceptual analysis of job satisfaction showed that this affective response behaviour

is not only linked to personal characteristics but also to one`s desired and expected outcomes.

Hence, this study investigated the influence of work environmental aspects and perceived health on

4,145 care workers in 162 Swiss nursing homes. Results showed that high job satisfaction was

associated with perceived supportive leadership (OR 3.76; CI 2.83-5.00), enhanced teamwork and

resident safety climate (OR 2.60; CI 2.01-3.33), the availability of nursing home director (OR 2.30; CI

1.67-2.97), and staffing adequacy (OR 1.40; CI 1.15-1.70). However, it was reduced in the presence

of workplace conflict (OR 0.61; CI .49-.76), compromised physical health (OR 0.91; CI 0.87-0.97),

and emotional strain (OR 0.88; CI 0.83-0.93). To retain care workers and recruit new ones, nursing

homes should modify substantial work environment (e.g. leadership and staffing adequacy) aspects

in order to promote job satisfaction among their staff. Future longitudinal research is needed to

confirm the observations made in this cross-sectional study design.

Finally, in Chapter 6 major findings of the individual studies are synthesized and discussed,

substantive theoretical findings are stressed, and methodological strengths and limitations of this

dissertation are presented. Moreover, implications for further research and clinical practice are

recommended. The findings of this dissertation add to the existing literature the first evidence

regarding the impact of health and presenteeism on rationing of care. Our findings confirm the

underlying theoretical assumption that safer work environment is a protective aspect of care workers`

13

health and wellbeing. Although these findings suggest the need to improve work environment and

care workers` health in Swiss nursing homes to ensure better provision of resident care, it remains

unclear whether improving care workers` health will lead to improved quality of care. This dissertation

will contribute to the further development of healthy workplaces and their relationship to job

performance and quality of care, and raises methodological issues that will require considerations in

future studies.

14

References

1. Stefanati, A., et al., [A survey on injuries among nurses and nursing students: a descriptive

epidemiologic analysis between 2002 and 2012 at a University Hospital]. Med Lav, 2015. 106(3): p.

216-29.

2. Sezgin, D. and M.N. Esin, Predisposing factors for musculoskeletal symptoms in intensive

care unit nurses. Int Nurs Rev, 2015. 62(1): p. 92-101.

3. Taghinejad, H., et al., Occupational mental health: A study of work-related mental health

among clinical nurses. J Clin Diagn Res, 2014. 8(9): p. Wc01-3.

4. Widmer, R., INTERIM RESULT : HOW DOES THE INTRODUCTION OF SwissDRG TO

LONG-TERM CARE OFF. 2013, CURAVIVA: Switzerland.

5. Zuniga F, et al., Rapport final de lènquete relative au personnel de soins et

dàccompagnement dans les établissments-médico-sociaux en Suisse. 2013, Institute of Nursing

Science-University of Basel: Basel.

6. Szymczak, J.E., et al., Reasons Why Physicians and Advanced Practice Clinicians Work

While Sick: A Mixed-Methods Analysis. JAMA Pediatr, 2015.

7. Bernal, D., et al., Work-related psychosocial risk factors and musculoskeletal disorders in

hospital nurses and nursing aides: A systematic review and meta-analysis. Int J Nurs Stud, 2015.

52(2): p. 635-648.

8. Rohde, K.A., et al., Minimizing nurses' risks for needlestick injuries in the hospital setting.

Workplace Health Saf, 2013. 61(5): p. 197-202.

9. Willemse, B.M., et al., The moderating role of decision authority and coworker- and

supervisor support on the impact of job demands in nursing homes: a cross-sectional study. Int J

Nurs Stud, 2012. 49(7): p. 822-33.

10. D'Arcy, L.P., Y. Sasai, and S.C. Stearns, Do assistive devices, training, and workload affect

injury incidence? Prevention efforts by nursing homes and back injuries among nursing assistants.

Journal of Advanced Nursing, 2012. 68(4): p. 836-845.

11. Qin, J., Kurowski, A., Gore, R., & Punnett, L. (2014). The impact of workplace factors on

filing of workers’ compensation claims among nursing home workers. BMC Musculoskelet Disord,

15(29), 2-9. doi: 10.1186/1471-2474-15-29

12. Letvak, S. and C.J. Ruhm, The impact of worker health on long term care: implications for

nursing managers. Geriatr Nurs, 2010. 31(3): p. 165-9.

13. Schwendimann, R., et al., Swiss Nursing Homes Human Resources Project (SHURP)

protocol of an observational study. J Adv Nurs, 2013. 70(4): p. 915-926.

15

16

CHAPTER 1

INTRODUCTION

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Health care is one of the high-risk industries for its employees. In 2014, the European

Agency for Safety and Health at Work (EU-OSHA) confirmed that healthcare workers having the

fourth highest rate of work-related health problems, just behind Manufacturing and Construction [1].

In the same line, the US healthcare sector is ranking with Transportation and Construction in non-

fatal injury rates among its workforce [2]. With no exception, Switzerland (2012) reported similar rates

of work related injuries per 100 full-time workers in Transportation (3.1), Construction (3.3), and

Health sector (3.1) [3]. In the health sector, more than half of the workforce is employed in hospitals

and nursing homes [4].

Nursing homes are a major component of long-term care provision in developed countries.

They operate 24 hours a day, 7 days a week, and 365 days a year, and often deal with issues of life

and death. Nursing homes face challenges, with the growing number of older people and the

introduction of DRG, as the length of hospital stay for patients has diminished and the discharge

accelerated [5]. Furthermore, according to the WHO (2012), approximately one third to one half of all

people who develop dementia will live in nursing homes [6]. In Switzerland, over 50% of residents

living in nursing homes are diagnosed with dementia or show the respective symptoms, and require

assistance to meet their basic needs [7]. Consequently, nursing homes deliver sub-acute care that

previously would have been provided in the hospital setting. Care services include rehabilitative and

palliative care to residents who can no longer sustain safely the basic activities of daily living in their

homes. As a result, professional care in nursing homes has become demanding due to high physical

workloads [8] and constant mental judgment to manage the needs of complex and fragile people [1].

Nursing home care workers (e.g. registered nurses, licensed practical nurses, certified nursing

assistants, nurse aides) perform various physical tasks that are particularly strenuous, such as lifting,

positioning, transferring residents, and working in awkward postures, which put them at risk for

injuries [9, 10]. In addition to physical strain and injuries, nurses are also at risk of mental health

problems, such as burnout and symptoms of depression [11] concomitant with the intensive nature of

labor and patient care. Although substantial research showed that emotional stress and mental

health illness are common problems among hospital care workers [12], little is known about the

magnitude of the problem in nursing homes.

Over the past two decades, care workers` safety has become a major area of interest in the

occupational health community. Several national and international organizations such as the Institute

of Medicine (IOM) [13], the World health Organization [14], the European Agency for Safety and

Health at Work (EU-OSHA) [1], the Occupational Safety and Health Administration [10], and the

National Institute for Occupational Safety and Health (NIOSH) [15] have provided evidence that

implementation of prevention programs, education, and strengthening the inspection bodies can

significantly reduce work-related injuries based on continuous research initiatives. There are ongoing

discussions on how to achieve a safer healthcare system not only for patients, but also for its

18

workforce too in order to reach a better quality care [1]. Accordingly, the focus on care workers health

has increased tremendously [16-18].

Despite these focused research and initiatives, the question remains whether the new

guidelines and programs implementation have also increased the ability to reduce work related

injuries and mental health illnesses. We have learned that despite many investments and

improvements [19, 20], the healthcare system is a complex and dynamic environment, which makes

it hard to sustain a high level of safety and injury-free environment. The promotion of care workers`

health is multidimensional and includes several factors such as physical and psychosocial work

environment conditions, personal health resources, and physical and social environment of the

broader community [14]. Reducing the incidents of injuries requires more than just the

implementation of an isolated program, as it may have ramifications on care workers, as well as on

the provision of care, and eventually on quality care [21]. In this sense, this dissertation sheds the

light on several gaps in the research of nursing home care workers` health, and offers one course of

many in the direction of increasing their safety and wellbeing.

1.1 Work related health among care workers: the magnitude of the problem

Working in the health sector and providing bed-side care entails dealing with a wide range of

activities and environments that pose a threat to care workers` health and puts them at risk of work-

related injuries and illnesses. Healthcare workers are exposed to a large number of concomitant risks

such as biological hazards (e.g. infections caused by needle stick injuries), chemical hazards (e.g.

toxic drug agents), ergonomic hazards (e.g. manual handling of patients), and psychosocial hazards

(e.g. violence against care workers) [1, 14]. The literature has identified physical and mental health

illnesses related to workplaces as follows.

Physical health

“The adult human form is an awkward burden to lift or carry. Weighing up to 100kg or more, it

has no handles, it is not rigid, and it is liable to severe damage if mishandled or dropped. In bed a

patient is placed inconveniently for lifting, and the placing of a load in such a situation would be

tolerated by few industrial workers” [22].

The substance of this quote has not changed fifty years later; nurses still handle patients in

beds and thus, continue to suffer from musculoskeletal injuries [23]. Work related musculoskeletal

injuries include problems in, but not limited to, the muscles, tendons, and joint nerves, with or without

tissue degeneration [24]. They are characterized by the feeling of pain, numbness, and/or heaviness.

These injuries could affect different areas of the body, such as superior and inferior limbs, back,

shoulder, and cervical region [24]. In nursing homes, elder residents depend on the healthcare

19

provider in meeting their daily needs such as bathing, toileting, and repositioning [19]. As a result,

movements including manual handling of residents (e.g. heavy lifting, frequent repositioning),

awkward body postures in performing daily tasks (e.g. bending, kneeling), transferring residents from

one place to another, and applying excessive forces while moving objects. In addition to lack of time

for recovery and speed of movement, were all associated with musculoskeletal disorders [1, 25, 26].

Several countries have ranked nursing home care workers, particularly frontline providers, among

workers with the highest incidence of back injuries [27] [28] [23] [29].

Moreover, care workers are at risk of sharp object injuries (e.g. needle stick injuries) while

performing their routine tasks, which were recognized as work-related health hazards [1, 30]. Sharp

object injuries place the nursing personnel at serious risk when exposed to blood and body fluids

(BBF) [30]. With exposure to BBF, approximately sixty pathogens are at risk to be transmitted,

including viruses, bacteria, parasites and yeasts, hepatitis B (HBV), hepatitis C (HCV) and human

immunodeficiency viruses (HIV) [1, 30, 31]. Most reported needle stick injuries occurred in the

hospital settings [32-34]. Less is known about exposures in long-term facilities [35]. For example,

during the parenteral exposure with a contaminated sharp object, the risk of infection with HIV, HCV,

and HBV, is 0.3%, 1.8%, and 30%, respectively [36]. Although research on sharp object injuries

focus on nursing personnel, most investigations on needle stick injury rates and trends are not

generalizable to other healthcare settings like nursing homes [30].

Some needle stick injuries go unreported by nurses [32, 35], which likely means that

previous research underestimated the magnitude of the problem. Not reporting injuries was linked to

embarrassment, lack of time, hesitancy to admit lack of knowledge on how to handle instruments,

and not knowing how and where to report [31].

Mental Health

In connection to dealing with highly care dependent residents, nursing home healthcare

workers face many difficult and potentially stressful situations [37]. With the increasing number of

aged people with dementia, elder care will continue to pose a challenge on industrialized countries in

the upcoming years. Researchers observed that nursing care, including managing challenging

behaviours and cognitively impaired residents, can induce psychological stress [38, 39], emotional

fatigue [1], and increases the risk for burnout [40]. In addition to physical strain, care situations often

requires high psychological demands, which includes frequent advanced communication skills, and

time dedication [17]. Feeling angry, tense, nervous, stressed, not able to cope, not able to sleep,

feeling tired and emotionally and/or physically exhausted, were all reported by nursing home care

workers to describe their psychological stress and mental health in the provision of care [38, 40].

Psychological stress can take the form of emotional exhaustion or burnout. Maslach (2001) defined

20

burnout as “a response to chronic interpersonal stressors on the job” and comprised emotional

exhaustion- the depletion of one’s emotional and physical resources [41].

A recent study in France revealed that over 30% of nurses working in nursing homes

reported compromised mental health [37]. Trends show that work-related mental health issues

among nursing home care workers is on the rise [37, 38, 42]. Compromised mental health among

care workers poses a number of problems for the professionals, the patients/residents, and the

organization in which they work, such as absenteeism [43], lower patient/resident safety [44],

intention to leave [45], and higher turnover rates [46]. The problem of staff turnover and shortage

causes additional challenges beside patient safety, such as the economic costs in recruiting and

training new personnel [46].

It is an ethical, moral, and legal obligation for employers to provide safe workplaces that do

not cause any type of harm to their staff, and to prevent burnout and emotional exhaustion, among

other health illnesses, from happening [47]. Consequently, the prevention of work related health

problems should be the focus of risk management in healthcare settings [46]. However, this requires

knowledge of the contributing factors. To date no comprehensive analysis of the situation in Swiss

nursing homes is available.

1.2 Presenteeism: an emerging problem

The term presenteeism emerged in the 1990s by Professor Cary Cooper, Professor of

Organizational Psychology and Health at Manchester University in the United Kingdom [48]. He used

the term to describe over-work and feelings of job insecurity that result from corporate downsizing

and restructuring. He did not initially link the term to going to work while ill. However, he indicated

that those individuals who consistently worked long hours would eventually become sick.

Presenteeism describes the loss of productivity from workers with legitimate health related problems,

such as headaches, colds, and allergies [48]. Fifteen years ago, the definition of presenteeism

evolved to describe the behavior of attending to work despite illness [49]. More recently in

healthcare, presenteeism referred to decreased job performance [50] or decreased work productivity

[21] due to illness, as a second indicator of productivity measurement [50], after absenteeism.

While absenteeism related to physical and mental illness gained a major emphasis in

occupational health research due to its associated cost [51], presenteeism has begun to garner more

interest from healthcare directors [50, 52]. Awareness to the subject relatively increased, when

organizations realized that not only absenteeism drains productivity, but also presenteeism [53].

Empirical studies showed that presenteeism is common among healthcare workers regardless of the

work setting [54, 55]. For example, in 2011, 49% of the Swedish public health sector workers

(including hospitals and primary care) reported frequent presenteeism [56]. Internationally, the

21

prevalence of presenteeism ranged from 22% to 62% among European and US hospital workers [57-

59].

Though in absenteeism, loss of productivity is 100% since workers` contribution is null, direct

and indirect loss of productivity costs in presenteeism are not easy to estimate [60]. Attempts to

quantify presenteeism rely solely on self-reports where respondents note when they had to turn up to

work while ill. As a result, measuring the impact of presenteeism on productivity was complex, which

made presenteeism a non-palpable phenomenon [61]. Subsequently, costs of presenteeism were

associated with low work ability [62], errors on the job, reduced work output, and failure to meeting

the organization standards and work expectations [63]. Productivity is an essential element for the

sustainability of the organization [47]. Shedding the light on this measure is crucial especially when

involving health professionals, due to the complex work obligations and the ramifications on

interpersonal relationships and care delivery [64]. As a consequence, presenteeism can have a

serious impact meeting residents` needs, since a nurse who remains on the job despite sick health

may not entirely meet its exigencies [59].

Another issue is that presenteeism involves a two-fold behaviour: one comprises the

legitimate sickness and the right to call in sick, and the second involves the decision to turn up to

work despite being ill [57]. In this sense, the question arises as to what make(s) care workers attend

to work despite illness. Although the increasing awareness of presenteeism losses are spiraling the

demand for health promotion programs [65], existing studies to promote care workers` health and

wellbeing in Europe and elsewhere [58, 66, 67] failed to explore comprehensively the second fold of

presenteeism, particularly in nursing homes.

1.3 Determinants of work-related health and presenteeism

Traditionally, studies on risk factors for work-related physical injuries (e.g. musculoskeletal

injuries) have focused on routine nursing tasks which involve manual resident handling and working

long hours or working shiftwork [20, 25, 68-70]. However, the benefits from prevention programs

such as training and accessibility to mechanical aides to reduce physical demands were not optimal

in reducing musculoskeletal injuries [71-73]. More recently, mounting evidence showed that

organizational factors play a role in the occurrence of work-related physical injuries [74-76].

Excessive use of the musculoskeletal system is influenced by inadequate work conditions: a

mismatch between the requirement of the task and care workers` ability to perform these tasks are

influenced by the characteristics of the work organization [24]. In nursing homes, positive and

supportive organizational culture promoted a safe work environment with reduced injury rates.

Psychosocial organizational factors included feeling supported, respected and valued by peers, and

collaborating with colleagues [72]. Other factors, which increased self-reported injuries, were limited

professional experience, poor training and job preparation, working overtime and doing shift work

22

[72]. Graham (2012) found that in an unfavourable work environment, care workers who suffered

from musculoskeletal injuries reported poor interpersonal relationships and negative job perception

[23]. The high prevalence of back injury is the major cause of absenteeism [77], and is reflected in

nurses’ placement among the highest of any professional healthcare group in their rates of manual

handling injuries [78]. Job demands, low job control, and low social support have explained the high

incidence of low back pain in hospital nurses [75].

Despite the fact that the relationship between psychosocial organizational factors and

musculoskeletal injuries has been widely examined, most of these findings are not generalizable to

all nursing home care workers, as they were limited to nurse aides [23, 72] and hospital care workers

[75]. Furthermore, associations between those factors and work-related musculoskeletal injuries are

confusing. The confusion lies to some extent in the lack of a standard definition of the psychosocial

aspects of the job [9]. For example work stressors (e.g. job demands, role conflict, lack of control)

and job strain (e.g. job dissatisfaction) were often pooled together [79], which make it difficult to

evaluate their impact on reported injuries [9].

In addition to the risk of musculoskeletal injuries due to handling patients, the risk of cutting

and piercing is high with handling sharp objects during patient care [31]. Empirical evidence showed

similarities between some organizational determinants of musculoskeletal injuries and sharp injuries

such as poor job training and little clinical skills [31, 32]. Sub-optimal compliance with safety

standards (e.g. recapping) [31, 32] and cleaning instruments after usage were also incidents in which

nurses reported injuries with sharp objects [80]. However, existing studies focused on hospital care

workers and nursing students, and did not account for the risk among nursing home care workers.

On top of work-related physical injuries, healthcare workers are also at risk of compromised

mental health. In particular, the nursing profession has long been known to be inherently demanding,

causing emotional exhaustion and burnout [81]. Psychosomatic symptoms, such as sleeplessness

and fatigue, were reported along with emotional exhaustion and burnout among care workers [82].

Previous research into professional emotional stress and burnout has shown that work environment

aspects influence mental health [83]. The identification of protective factors became the centre of

attention in emotional stress research due to their implications for personnel education and job

restructure [81].

Although few studies have examined the relationship between the work environment aspects

and emotional exhaustion in the nursing home setting, evidence has shown that high job demands,

work autonomy [84], and job dissatisfaction [82] were contributing factors. In the provision of care for

complex and challenging residents, the management has the influence on care workers` job

satisfaction through greater leadership support and reduced occupational stress [38]. According to

the Demand-Control-Support Model, the effect of job demands on one`s mental health is buffered

when job control and social support at work are optimal [85]. For instance, in a German study on

23

nursing home care workers, an interaction between job control and job demands in relation to

physical health complaints and emotional exhaustion was observed [86].

Apart from the job psychosocial characteristics and its potential impact on the health of care

workers, several investigators found that resident violence toward healthcare workers resulted in high

level of work-related stress and burnout [87]. The National Institute for Occupational Safety and

Health defines workplace violence as “violent acts, which include physical assaults and threats of

assaults, directed toward persons at work or on duty” [88]. Empirical research reveals that the

prevalence rates of resident violent acts against care workers in US nursing homes are high [89]. Not

enough time to assist residents with activities of daily living was reported as a trigger for the assault.

Nurses who reported experiencing the assault, described feeling of emotional stress [89]. In an

attempt to raise awareness and promote care workers safety and wellbeing, special guidelines for

handling challenging behaviour for residents with dementia in nursing homes were published in 2007,

entitled “Guidelines for the Care of People with Dementia and Challenging Behavior”. However,

violence against care workers is still high in nursing homes, and was linked to compromised physical

and mental health [87].

As it relates to health, the importance of presenteeism relies primarily in its loss of

productivity, which may exceed that of absenteeism [59]. Similar to physical and mental health,

unfavourable psychosocial work environments were also linked to presenteeism [58]. Job demands

[53] and ease of replacement [90] were correlates of presenteeism. The ability to work through illness

depends on the person`s perception that fellow colleagues will not be able to compensate for his/her

absence [58]. However, a previous study on hospital care workers showed that time pressure, and

the inability to find a substitute, were not related to the decision to come to work while ill [91].

To date, results regarding organizational factors in relation to presenteeism do not explain its

magnitude due to their low explanatory power [90]. This suggests that the field of presenteeism

warrants further investigations. Other than studies examining the prevalence and circumstances of

injuries, there is little research examining risk factors associated with injuries experienced by nursing

home care workers, and knowledge about the impact of organizational factors on nursing home staff

injuries is limited. There is a mounting body of evidence that endorses the creation of a “healthy”

workplace environment in order to support healthcare providers, retain qualified personnel, and

ultimately guarantee the delivery of optimal and safe quality of care [16, 47, 72]. Hence, knowing the

contributors of presenteeism comprehensively help nursing directors and managers observe

symptoms of presenteeism and modify working conditions in order to avoid any repercussions on job

performance (e.g. rationing of care), and eventually quality of care.

24

1.4 Effect of health and presenteeism on rationing of care

Care workers` compromised health has a direct impact on the organization through loss of

productivity [37]. For decades, productivity was measured by workplace absences due to illness [92].

However, with the emergence of presenteeism, there has been little research into how nurses’ health

and the level of productivity might relate to their ability to provide care [59]. Previously, Michie (2003)

observed that care workers` poor health impact patients, in that both the quantity and the quality of

care may be reduced [93]. More recently, nursing home staff who reported highest burnout and

lowest general health, scored lowest on their ability to work [40]. Nursing productivity is often viewed

as “doing one`s work as carefully as usual, as measured by self-report” [59], and assessed in relation

to reduced work output, errors on the job, and failure to meet organization production standards [50].

In a study on physical and mental fatigue among nurses in relation to their performance [94], the

survey assessed the frequency of nurses following existing organizational work standards in patient

handling, modifying standards to get the work done, performing physical tasks (e.g. handling

patients), patient monitoring, documentation, and/or communicating with patients or family members,

and taking short-cuts in patient care. Findings showed that the higher the physical and the emotional

fatigue, the lower the nursing performance [94]. In that, based on their assessments, nurses often

make important decisions to leave certain tasks undone [95]. There have been previously numerous

studies on the omission of nursing care, and three concepts were identified: 1) nursing care left

undone [96], 2) missed nursing care [97], and 3) implicit rationing of care [98]. Despite the difference

in operationalization, these three concepts refer to care workers` attempts in omitting partially or fully

nursing activities during scarce resources (e.g. time pressure, shortage of staff) [95, 97] and physical

and emotional fatigue [94].

Consequently, in a demanding work environment like the nursing home, it is important to

know the most critical factor(s) that affect the decision of omission of care and subsequent nursing

performance. As such, the role of compromised health of care workers and presenteeism in relation

to implicit rationing of care must be clarified because nurses’ role in providing the majority of direct

patient care is closely tied to the quality and safety of care [99], and because studies have stressed

that rationing of care is a correlate measure of nursing care quality [100].

1.5 The effect of work environment and health on job satisfaction

In the first half of the 21st century, the global population 60 years and over is expected to

expand threefold to nearly two billions [101]. With this dramatic increase in elder population come the

sharp increases in dementia [102, 103], and subsequently the upsurge need for dementia care.

Hence the demand for nursing home care workers will amplify. Recruitment and retention are among

the challenges that face long -term facilities to keep up with the pressing demands [104]. Numerous

25

factors have been linked to care workers` turnover; yet, job satisfaction is by far the most cited [105].

It is an affective reaction describing a pleasure or emotional state resulting from the appraisal of

one`s job experiences [106]. Although several nursing homes offered some combination of retention

programs, the majority of strategies did not have a significant association with the level of nursing

retention [107]. Furthermore, not all dissatisfied care workers leave their work, but they might exhibit

unreliable work ethic [108] and impact the quality of resident care delivered [109]. The determinants

of job satisfaction for care workers may vary across health care systems [108]. Hence factors

influencing hospital care workers` job satisfaction might not be generalizable to nursing home care

workers. Despite the significance of job satisfaction, studies examining determinants of job

satisfaction comprehensively are lacking in nursing homes [108].

1.6 The WHO Model for Healthy Workplace

For this dissertation thesis, we used the World Health Organisation Model for Healthy

Workplace to guide our empirical examination (fig.1). The model represents the structure, content,

processes and system of the healthy workplace concept. It includes both the content of the issues

that should be addressed in a healthy workplace, grouped into four large “avenues of influence”, as

well as the process for continual improvement that will ensure sustainability of healthy workplace

initiatives [47]. Critical process aspects of the model include a step-by-step continual process of work

environment involvement around a shared set of ethics and values [14].

26

Figure 1. The WHO Model of Healthy Workplace

27

As described by the model, the four key areas that can be influenced in healthy workplace

initiatives are 1) the physical work environment hazards typically include chemicals, biological, and

ergonomic hazards (e.g. processes requiring excessive force). These factors can affect workers`

physical and mental health; 2) the psychosocial work environment refers to the organisational culture

and daily practices that affect the mental and physical health of the workers. Workplace stressors are

factors that might cause emotional or mental stress. Psychosocial hazards include poor work

organization (e.g. time pressure, poor leadership support and communication), organisational culture

(e.g. bullying), and control management (e.g. lack of consultation and constructive feedback, and

disrespectful performance management; 3) personal health resources are the health services and

supportive environment an organization provides to workers to monitor and improve physical and

mental health; and 4) enterprise involvement in the community refers to the activities in which an

organization might provide to support the social and physical wellbeing of a community in which it

operates.

Besides the ethical and moral legal principle of doing no harm, workplaces require workers in

order to attain their objectives, and there is a strong business case to be made for ensuring that

workers are mentally and physical healthy through health protection and promotion. Unhealthy and

unsafe workplace impact on employees` stress can induce different outcomes, such as accidents

and injuries, burnout and depression. Those factors in turn have a negative impact on workers, such

as increased absenteeism and presenteeism, and reduced job satisfaction. Consequently, costs and

productivity losses are increased with a decline in quality of customer service.

1.7 Identified research gaps and dissertation rationales

In summary, the following gaps in the scientific literature on care workers` health guided the

development and implementation of this dissertation.

First, previous nursing home research has addressed some issues on work-related injuries of

care workers in the nursing home setting. However, most related studies have focused on

musculoskeletal injuries or burnout and emotional exhaustion. Very few taped into alerting symptoms

that could be an early indication of emotional exhaustion. Furthermore, needle stick injuries and other

health problems such as allergies were not investigated in nursing homes. Existing studies have not

comprehensively examined the various risk factors affecting the health of the care workers including

psychosocial work environment aspects.

Second, even less research has been conducted on care workers presenteeism in

comparison to absenteeism. Additionally, there are no Swiss nursing home studies in this regard.

Trends and rates of presenteeism were mostly investigated in hospital settings. Related studies

focused on very few aspects of the work environment rather than a comprehensive assessment of

underlying risk factors.

28

Third, absenteeism has been widely investigated in association to its costs. However,

presenteeism and its impact of care workers` job performance were less researched in nursing

homes internationally, as well in Switzerland. Our understanding is that compromised health and

presenteeism reduce job performance in that care workers will not follow organization guidelines in

the provision of care and apply short cuts in the care [94], hence rationing of care might occur.

Fourth, care workers` job satisfaction is a significant factor in reducing care workers` turnover

and retaining qualified staff. We learned from the literature that job satisfaction does not rely solely

on individual characteristics, but also on one`s expectations and the nature of the job. Hence the

need arises to investigate the most crucial factors in the nursing home work environment, which

reduce or promote job satisfaction.

Given the knowledge gaps remaining to be filled, the following rationales apply for this

dissertation.

First, a study is necessary to explore the prevalence of physical and mental health issues,

and comprehensively investigate the underlying influential factors regarding care workers` s health in

nursing homes that link between psychosocial work environment aspects and compromised physical

and mental health. Empirical evidence on the relationship between work environment factors and

compromised care workers` health is critical to the planning and implementation of measures

reflecting on work environment modification, and will be necessary to justify initiatives and

mobilization of efforts that aim to improve overall care workers health by improving the work

environment aspects.

Second, the emerging of presenteeism and its effects on loss of productivity makes it crucial

to explore the trends of such behaviour among nursing home care workers, in comparison to

absenteeism. Examining the underlying risk factors that may influence the decision of nurses to turn

up to work despite illness help managers and nursing directors better understand this phenomenon

in order to validate initiatives that detect such behaviour. Reduce presenteeism implies promoting

productivity and job performance to eventually ensure quality of care.

Third, understanding the impact of compromised health and presenteeism among nursing

home care workers on rationing of care is a crucial element to ensure nursing adequate job

performance and eventually quality of care.

Fourth, with the growing number of older people and the pressing need for long-term care in

an era of care workers` shortage, identifying the influential factors on care workers` job satisfaction

could be promising strategies to ensure care workers retention and adequate provision of safe care

to residents.

Thus, the proposed dissertation will contribute to the international scientific literature, as well

as expanding the existing knowledge and care workers` health in Swiss nursing homes.

29

1.8 Study aims

Given the identified gaps in the literature regarding care workers health in nursing homes, this

research project includes the following aims:

• To explore the prevalence of physical and mental health outcomes among care workers in

Swiss nursing homes (Chapter 2)

• To examine the association between selected factors in the psychosocial work environment

and health outcomes of care workers (Chapter 2)

• To determine the prevalence of absenteeism and presenteeism among professional care

workers in Swiss nursing homes (Chapter 3)

• To explore psychosocial work environment factors’ associations with absenteeism and

presenteeism (Chapter 3)

• To examine the prevalence of nursing home care worker-reported rationing of care (Chapter 4)

• To explore the relationships between care workers` health, presenteeism and rationing of

care in nursing homes (Chapter 4)

• To determine job satisfaction among nursing home health care workers (Chapter 5)

• To examine the association between work environment factors and care workers’ health

issues in a representative national sample of nursing homes (Chapter 5).

30

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38

CHAPTER 2

CARE WORKERS HEALTH IN SWISS NURSING HOMES AND ITS

ASSOCIATION WITH PSYCHOSOCIAL WORK ENVIRONMENT

Suzanne R. Dhaini¹ MA, Franziska Zúñiga 1 PhD, Dietmar Ausserhofer1, 2 PhD, Michael Simon1,3 PhD,

Regina Kunz4 MD, Sabina De Geest¹ PhD, Rene Schwendimann1 , PhD

1Institute of Nursing Sciences, University of Basel, Switzerland

2Claudiana, University of Applied Science, Bolzano (BZ), Italy

3Inselspital Bern University Hospital, Nursing & Midwifery Research Unit, Switzerland

4 Swiss Academy of Insurance Medicine, University Hospital Basel, Switzerland

Published in the International Journal of Nursing Studies, 2016, 53, pp. 105-115. DOI:

10.1016/j.ijnurstu.2015.08.011

39

2.1 Abstract

Background: Previous studies have demonstrated poor health of care workers in nursing

homes. Yet, little is known about the prevalence of physical and mental health outcomes, and their

associations with the psychosocial work environment in nursing homes.

Objectives: (1) To explore the prevalence of physical and mental health outcomes of care

workers in Swiss nursing homes, (2) their association with psychosocial work environment.

Methods: This is a secondary data analysis of the cross-sectional Swiss Nursing Home

Human Resources Project (SHURP). We used survey data on socio-demographic characteristics

and work environment factors from care workers (N=3,471) working in Swiss nursing homes

(N=155), collected between May 2012 and April 2013. GEE logistic regression models were used to

estimate the relationship between psychosocial work environment and physical and mental health

outcomes, taking into account care workers` age.

Results: Back pain (19.0%) and emotional exhaustion (24.2%) were the most frequent self-

reported physical and mental health. Back pain was associated with increased workload (OR 1.52, CI

1.29-1.79), conflict with other health professionals and lack of recognition (OR 1.72, CI 1.40-2.11),

and frequent verbal aggression by residents (OR 1.36, CI 1.06-1.74), and inversely associated with

staffing adequacy (OR 0.69, CI 0.56-0.84); emotional exhaustion was associated with increased

workload (OR 1.96, CI 1.65-2.34), lack of job preparation (OR 1.41, CI 1.14-1.73), and conflict with

other health professionals and lack of recognition (OR 1.68, CI 1.37-2.06), and inversely associated

with leadership (OR 0.70, CI 0.56-0.87).

Conclusions: Physical and mental health among care workers in Swiss nursing homes is of

concern. Modifying psychosocial work environment factors offer promising strategies to improve

health. Longitudinal studies are needed to conduct targeted assessments of care workers health

status, taking into account their age, along with the exposure to all four domains of the proposed

WHO model.

40

2.2 Introduction

The WHO defines a healthy workplace as a place that “(…) provides all members of the

workforce with physical, psychological, social and organizational conditions that protect and promote

health (…)” [1]. Care workers in health services are at substantial risk for compromised health, both

physically and mentally [1]. In 2012, Switzerland reported 3.1 injuries per 100 full-time workers in the

health sector [2], similar to those reported in the U.S. health sector [3]. Physical health includes not

only diagnosed illnesses, but also conditions in which the person has no specific disease, yet is not

at optimal health. Similarly, mental health may not always reach the level of a diagnosable disorder,

yet it can still make the worker suffer [1].

While recent studies have extensively examined the physical and mental health of hospital

care workers [4-7], the nursing home setting has been less researched internationally. For example,

in Switzerland, the introduction of Diagnostic Related Group (DRG) [8] has set the trend for nursing

homes to deliver sub-acute care to residents with complex medical conditions. The majority of

residents is diagnosed with dementia or demonstrates the symptoms, and requires assistance in the

activities of daily living. Despite the availability of some ergonomic tools for lifting, care workers do

not use them consistently, and they participate in some high risk nursing tasks (e.g. injections of

medications and capillary/venous blood sampling). As a result, nursing home care workers perform

many physically & emotionally straining activities that put them at risk of injuries.

Musculoskeletal injuries (e.g. back pain) have been reported as one of the most predominant

physical health outcomes among care workers in nursing homes [9, 10], where job demands require

frequent handling of patients in bed. Consequently, care workers often complain of back pain [11,

12]. Several of the studies that have examined musculoskeletal injuries, found that a positive work

environment, including social support at work [13], good relationship with colleagues [14], and the

availability of ergonomic equipment and training programs, was associated with a decrease in the

rate of compensation claims for injuries [15-17]. However, most of these findings are not

generalizable to all nursing home care workers, as they were limited to nurse aides [18].

Another risk for compromised physical health condition is the exposure to needle stick

injuries [19] and skin diseases [20, 21]. Previous studies found that the lack of training might explain

the occurrence of these injuries [22] and dermatitis [21]. Despite the mounting risk, only few studies

have examined the risk of needle stick injuries in nursing homes [19].

In addition to the physical strain and injuries, nurses are at risk of fatigue and emotional

stress [23]. The transactional theory suggests that work environment and its stressors cause

psychological strain responses in the person [24], which has an impact on the worker emotional

health, such as feeling overwhelmed with work situations [25]. Some studies have identified work

environment stressors as incompatible role expectations from the supervisor, interpersonal conflict,

leadership styles and abusive supervision [25]. Nonetheless, few studies have examined the

41

relationship between the work environment and emotional exhaustion in the nursing home setting.

Evidence has shown that the work environment, specifically high job demands [26, 27], high

workload, and low job autonomy [27] are associated with emotional exhaustion. Furthermore, a

recent study on hospital nurse aides found that workplace violence was associated with minor

emotional disorders [28].

2.3 Conceptual Framework

The WHO Model of Healthy Workplace [1, 29] was proposed to describe the key components of a

healthy workplace. The model focuses on four fundamental domains, specifically 1) the physical work

environment, 2) the psychosocial work environment, 3) personal health resources, and 4) the

enterprise community involvement to provide guidance for employers to explore worker`s health and

to intervene, in order to sustain the organization. Our goal in this study is to examine to what extent

selected factors (based on data available through the SHURP study) within one of the model

domains, the psychosocial work environment, exist and related to care worker physical and mental

health outcomes (Figure1). The psychosocial work environment includes the organizational culture

and daily practices, which can affect both physical and emotional health, and may include work

stressors, percentage of residents with dementia, staffing resources inadequacy, poor leadership,

lack of workers` participation in decision making, poor collaboration with the management and

among colleagues, low job autonomy, and workplace violence.

To date, there is a lack of international as well as Swiss studies about the health of nursing

home care workers (including registered nurses, licensed practical nurses, certified nursing

assistants, and nurse aides) and the impact of the work environment as a risk factor. Accordingly, the

purpose of this study was to

1. Explore the prevalence of physical and mental health outcomes among care workers in Swiss

nursing homes.

2. Explore the association between selected factors in the psychosocial work environment and health

outcomes of care workers.

42

Figure 1. The WHO Model of Healthy Workplace

Adopted from Burton (2010) [1] & Neira (2010) [29]

Care worker s` health outcome

Physical health

Back pain

Joint ache

Needle stick injuries

Allergies

Mental health

Sleeplessness

Tiredness

Headache

Emotional exhaustion Emotion

43

2.4 Methods

2.4.1 Study design, setting, and sample

This is a secondary data analysis of the multi-center, cross-sectional study Swiss Nursing

Homes Human Resources Project (SHURP). Sampling and survey methods of the SHURP study are

described in detail elsewhere [30].

The SHURP study included a representative random sample of 162 nursing homes across

Switzerland, stratified according to language region, size, and profit status of the nursing home.

Nursing homes smaller than 20 beds, residential homes, and rehabilitation clinics for geriatrics were

excluded. After excluding facilities and units that did not provide data on unit level characteristics, a

sub-sample of 155 facilities was included in the current study.

In the parent study, 6,947 questionnaires were distributed and 5,323 were returned resulting

in an overall 76.6% response rate. Care workers of all educational levels who provided direct care to

the nursing home residents, in addition to managers of the nursing home facilities, were invited to

complete the questionnaire survey. Care workers who had worked less than 8 hours weekly, less

than 1 month on the unit, or who were students were excluded. In the current study, we excluded

respondents with leadership positions (middle and upper management n=805) regardless of their

professional category (registered nurses and licensed practical nurses), and units with missing

responses from the total sample, resulting in a sub-sample of 3,471 care workers (including

registered nurses, licensed practical nurses, certified nursing assistants, and nurse aides).

2.4.2 Data sources, variables and measurements

Socio-demographic and professional data on care workers, including their perception of their

work environment, work stressors, workplace violence, and physical and mental health outcomes,

were collected using the Care worker Personnel Questionnaire of the SHURP study.

The nursing home facility characteristics and the number of residents with dementia present

on the unit were captured from the administration SHURP Facility Profile and Unit Profile

questionnaires, respectively.

The SHURP study has established the content validity of each of the scales used by testing

the relevance of each variable and scale separately, and obtaining item content validity index (I-CVI)

and scale content validity index (S-CVI), respectively. Further information related to the development

of the questionnaire and the survey validity pre-testing are described elsewhere [30]. In the current

study, we used the following variables:

44

Care worker and facility characteristics

Care workers and facility characteristics are used as control variables (except for care

workers` age, treated a risk factor) to describe the study sample, as they are major in this topic. The

socio-demographic data included: age; gender; professional category (i.e. registered nurses,

licensed practical nurses/certified nursing assistants, nurses aides); professional experience in

nursing in years; percentage of time employed corresponding to number of hours worked per week

(ranging from 8hrs/week=20% to 42hrs/week=100% employment); usual work shifts

(days/evenings/nights, days/evenings, or night shifts); overtime frequency (1 to 4 ranging

from1=almost every shift, 2=every 2-4 working days, 3= every 5-7 working days, to 4=less

frequently). The professional categories of the care workers were based on their nursing education

level, as follows: registered nurses with three to six years of education holding a diploma in nursing,

bachelor degree (BSc.N. or equivalent) or higher; licensed practical nurses (LPN)/certified nursing

assistants (CNA) with three and two years of education respectively; and nurse aides with short

courses or on-the-job training. Care workers` age (in years); 1=18-30; 2=31-40; 3=41-50; 4=older

than 50) was treated as a risk factor as it may have an impact on different health outcomes.

Facility characteristics included nursing home size (ranging from small: 20-49 beds, medium:

50-99 beds, to large: ≥100 beds), language region (German-, French-, Italian speaking area), and

ownership status (private, private subsidized, public).

Physical and mental health outcomes

Four physical health outcomes were examined: self-reported back pain, joint pain, needle

stick injuries, and work-related allergies. The occurrence of back pain and joint pain during the 4

weeks prior to the survey was measured on a 3-point Likert scale (1=not at all, 2=a little bit,

3=strongly) by two items from the Swiss Health Survey for [31]. For needle stick injuries, an item

from the RICH-Nursing study questionnaire [32] was used to ask care workers if they had injured

themselves during the last 6 months with a needle stick or a sharp tool that was used on a resident in

their nursing home (0=no injury, 1=yes). An investigator-developed item with a 3-point Likert-type

response option (=not at all, 2=a little bit, 3=strongly) was used to ask about work-related allergies

such as dermatitis and asthma during the past 4 weeks.

Four mental health outcomes were measured: self-reported tiredness, sleeplessness,

headache, and emotional exhaustion related to work. The presence of tiredness, sleeplessness, and

headache during the past 4 weeks was measured on a 3-point Likert scale (1=not at all, 2=a little bit,

3=strongly) using items from the Swiss Health Survey [31]. The feeling of exhaustion from work was

measured on a 7-point Likert scale (ranging from 0=never, to 6=daily) using an item from the

Maslach Burnout Inventory (MBI) [33].

45

Psychosocial work environment factors

Work stressors items were selected from the Health Professions Stress Inventory (HPSI) [34,

35] to measure the frequency of several work-related stressors measured by a 5-point Likert scale

(0=never, 1=seldom, 2=sometimes, 3=often, 4=very often). To reduce the survey burden, we asked

experts (holding at least a Certificate of Advanced Studies up to a Master’s degree with experience in

nursing home care) from the gerontological field concerning the relevance of each question. Each

item was rated for its understandability for nursing home personnel (yes/no), and for its relevance

concerning resident safety on a 4-pont scale (1=not relevant, 2=somewhat relevant, 3=quite relevant,

4=very relevant). The item content validity (I-CVI) was calculated for each item as the percentage of

experts who rated it 3 or 4. The average scale content validity (S-CVI/Ave) was calculated as the

mean of all I-CVI. Reducing the items from 30 to 12, the psychometric analysis of the remaining

items produced 3 sub-scales tested for internal consistency (Cronbach`s alpha) and measuring

stress-producing factors: stress due to (1) workload (Cronbach alpha 0.73), (2) a lack of job

preparation (Cronbach alpha 0.63), and (3) conflict and lack of recognition (Cronbach alpha 0.76).

Stress due to workload was measured by three items that asked about dealing with difficult

situations, having too much work to do, and there not being enough people working. Stress due to

lack of job preparation was measured by three items asking about fear of committing mistake, being

overwhelmed when caring for terminally ill residents, and not being prepared to meet the residents’

needs. Conflict and lack of recognition was measured by six items that asked about disagreement

with other professionals, conflicts with superiors, lack of information, not being asked about one’s

opinion, low pay, and underuse of skills. “Conflict” and “lack of recognition” were combined based on

Exploratory Factor Analysis. The SHURP team did a multiple group EFA (three language region

groups), and all factor loadings of the subscale conflict and lack of recognition were significant and

above 0.3 (range 0.371-0.734; 90% CI 0.043-0.050).

The percentage of residents with dementia was calculated in reference to the total number of

residents present on the units at the time of the survey. Residents diagnosed with dementia or

manifested symptoms of dementia were included. This factor is included since it often involves

complex labor working with cognitively impaired residents and can induce stress among nursing

home care workers.

Care worker perceptions about nursing home leadership and staffing adequacy were

measured by items adapted for nursing home use from two subscales of the Practice Environment

Scale of the Nursing Work Index (PES-NWI) questionnaire [36]: “Nurse manager ability, leadership,

and support of care workers” (Cronbach alpha 0.843) and “Staffing and resources adequacy”

(Cronbach alpha 0.743), respectively. Leadership included whether unit supervisor was perceived as

supportive and as a competent leader, whether mistakes are used as a learning opportunity, an

whether care workers receive reward and recognition for a job well done, and back up in decision

46

making. Staffing adequacy included enough staff to get the work done, to provide quality care, and to

discuss resident problems. Additionally, a single item assessing participation in decision-making was

used. Items were rated on a 4-point Likert scale (1=strongly disagree, 2=slightly disagree, 3=slightly

agree, 4=strongly agree).

Collaboration with the nursing director and collaboration with colleagues were adopted from

the Safety Attitude Questionnaire (SAQ) [37], rated on a 4-point Likert scale (1=very low, 2=rather

low, 3=rather high, 4=very high), allowing the answer option “don’t know”. In small sized nursing

homes, the nursing director can hold managerial responsibilities such as nursing supervisor duties.

As a result, all care workers can have collaboration with the nursing director. To measure autonomy

at work, one investigator-developed item was used to ask care workers to rated the extent to which

they agreed that they decided on their own how to go about doing their work. The item was rated on

a 4-point Likert scale (1=strongly disagree, 2=slightly disagree, 3=slightly agree, 4=strongly agree).

Workplace violence was measured by the residents’ verbal and physical aggressive behaviours toward care workers. The descriptions of verbal or physical aggression were derived from

the Ryden`s Aggression Scale [38]. Care workers were asked about the frequency of resident

physical and verbal aggressive behaviour towards them during the past 4 weeks on a 6-point Likert

scale (0=never, 1=less than once a week, 2=approximately once a week, 3= several times a week,

4=daily, 5=several times a day).

2.4.3 Data collection and analysis

The SHURP survey was administered between May 2012 and April 2013. Further

information related to data collection is described elsewhere in detail [30].

To address aim 1, we calculated descriptive statistics (frequencies, percentages, means,

standard deviations). For aim 2, we first used a bivariate logistic regression to explore associations

between facilities and care workers characteristics and each physical and mental health outcome.

We used generalized estimation equation (GEE) multiple regression models to take the clustering of

care workers in nursing home units into account. In a second step, we used multiple logistic GEE

regression models to estimate odds ratios (ORs) and 95% Confidence Intervals (CI) for risk factors

(psychosocial work environment), adjusted for facility and care workers characteristics. We

dichotomized all health outcomes in order to capture care workers with self-reported compromised

health: back pain, joint ache, allergies, sleeplessness, tiredness, headache: 0= not at all and a little

bit, 1=strongly; needle stick injuries: 0=no, 1=yes; emotional exhaustion: 0= never, several times a

year or less, once a month or less, and several times a month, 1= once a week, several times a

week, and daily. We also assessed multi-collinearity of all work environment factors with the variance

inflation factor (VIF). Based on the VIF, all variables were kept because all values remained below

the threshold of 5 [39]. To explore the robustness of the analysis to the model specifications we run

47

the same regression equations with dependent variables specified as ordinal variables, indicating

similar results as in the binary logistic regression models. The maximum of missing responses per

variable was 5%. We therefore applied list wise deletion to deal with missing data. All data analyses

were conducted with IBM/SPSS for Mac Statistics 21.0.We report adjusted results of our GEE logistic

regression models analysis.

2.4.4 Ethical approval

The study aims are covered by the SHURP study, for which the ethic committee of the state

of ‘Beider Basel’ (Ref. Nr. granted ethical approval. EK:02/12) gave approval. All participating nursing

home administrators and nursing directors gave written consent for the SHURP study. The return of

the care worker SHURP questionnaires was treated as an informed consent.

2.5 Results

2.5.1 Description of sample

Overall, 155 nursing homes, and 3,471 care workers participated in the study. Table 1

summarizes the characteristics of the facilities and the participants, as well as the work environment

factors. Across all facilities, the majority of care workers were females (92.4%) and one third (33%)

were older than 50 years. One fourth of the participants were registered nurses (23.6%), while the

largest professional category was licensed practical nurses /certified nursing assistant (42.9%). As

for employment percentage, less than one third were employed either full time (23.2%) or up to 50%

(21.7%), with more than 20 years of nursing experience (23.9%). The majority of the respondents

(75.0%) reported overtime less than once a week and only 2% reported doing overtime every shift.

The majority of respondents worked day/evening shifts (56.3%). The care workers experienced a

high degree of participation in decision-making (86.4%), collaboration (88.5%), and autonomy

(80.8%) at work, all measures of psychosocial work environment. In terms of workplace violence,

25.3% of the respondents experienced verbal aggressiveness by residents several times a week or

more often in the past four weeks.

48

Table 1. Characteristics of nursing home facilities, care workers, and work environment factors

Nursing home characteristics (N=155 facilities) n (%) Means (SD)

Language speaking region

German

French

Italian

117 (75.5)

29 (18.7)

9 (5.8)

Profit status

Public

Private subsidized

Private

68 (37.4)

40 (25.8)

57 (36.8)

Nursing home size

Small (20-49beds)

Medium (50-99 beds)

Large (≥100 beds)

60 (38.7)

73 (47.1)

22 (14.2)

Care worker characteristics (N=3,471)

Gender (n= 3456)

Females

3192 (92.4)

Age groups (years)(n=3402)

18-30

31-40

41-50

>50

751 (22.1)

600 (17.6)

929 (27.3)

1122(33.0)

1Nursing job category (n=3471) Registered Nurse

LPN/CNA

Nurse Aide

912 (26.3)

1488 (42.9)

1071 (30.9)

49

Employment percentage (n=3430)

Up to 50%

51%-90%

>90%

745 (21.7)

1889 (55.1)

796 (23.2)

Professional experience in nursing (years) (n=3360)

Up to 5

6-10

11-15

16-20

>20

720 (21.4)

803 (23.9)

613 (18.2)

420 (12.5)

804 (23.9)

Overtime Frequency (n=3450)

Almost every shift

Every 2-4 working days


Less frequently

65 (1.9)

285(8.3)

511 (14.8)

2589 (75.0)

Usual shifts (n=3446)

Regular change of shift

Day/evening only

Night only

1294 (37.6)

1939 (56.3)

213 (6.2)

Psychosocial Work Environment

Leadership (n=3471) 3.14 (0.60)

Work stressors

Workload (n=3467)

Lack of job preparation (n=3464)

Conflict & lack of recognition (n=3467)

Residents (%) with dementia (n=401 units)

1.56 (0.83)

0.68 (0.59)

0.91 (0.67)

61.85 (24.41)

50

Staffing adequacy (n=3468) 2.82 (0.67)

2Workplace Violence towards care worker

(Several times a week to several times a day)

Verbal aggression (n=3456)

Physical aggression (n=3455)

873 (25.3)

394 (11.4)

3Participation in decision making (n=3455) 2985 (86.4)

4Collaboration with

Nursing Director (n=3271)

Colleagues (n=3429)

2894 (88.5)

3281 (95.7)

3Autonomy (n=3450) 2786 (80.8)

1 Registered nurses or higher received 3-6 years of education; licensed practical nurses (LPN)/certified nursing assistant (CNA) received 2-3 years of education; nurse aides received on the job training. 2Workplace violence: 0=never, less than once a week, approximately once a week; 1= several times a week, daily, several times a day; 3Participation& autonomy: 0=strongly disagree, slightly disagree, 1=slightly agree, strongly agree; 4collaboration: 0=very low, rather low; 1=rather high, very high; 2= Don’t know. Group “1” is being reported.

51

2.5.2 Prevalence of Care workers health outcomes

Of the care workers, 38% and 27.4% reported at least one compromised physical health and

one mental health outcome, respectively. Back pain (19.0%) and joint pain (13.5%) were more

frequent in comparison to needle stick injuries (2.1%) and allergies (1.0%) (Table 2). Mental health

outcomes were more prevalent than physical health outcomes. Emotional exhaustion from work

(24.2%) was more common than tiredness (14.4%), sleeplessness (12.6%), and headaches (9.9%).

52

Table2. Prevalence of workplace physical and mental health outcomes

Physical health outcomes (care worker-reported) n (%)

*Needle stick injuries (n=3457)

71 (2.1)

**Allergies (n=3459)

36(1.0)

**Back pain (n=3450)

655 (19.0)

**Joint pain (n=3446)

464 (13.5)

Total physical health outcomes (n=3410)

≥ 1 Physical health reported outcomes

1296 (38)

Mental health outcomes (care worker-reported) n (%)

**Sleeplessness (n=3442)

432 (12.6)

**Tiredness (n=3442)

494 (14.4)

**Headache (n=3430)

339 (9.9)

***Emotional Exhaustion (n=3442)

834 (24.2)

Total mental health outcomes (n=3433)

≥ 1 Mental health reported outcomes

939 (27.4)

*Needle stick injuries: 0= no, 1=yes; **Allergies, Back pain, joint ache, headache, tiredness, sleeplessness: 0=never & a little bit; 1=strongly; ***Emotional exhaustion: 0= never, several times a year or less, once a month or less, and several times a month, 1= once a week, several times a week, and daily. Group “1” is being reported.

53

2.5.3 Association between work environment and care workers` health

In the development of the model, the analysis showed no differences among professional

categories in relation to health outcomes. However, along with age, psychosocial work environment

factors were correlated with care worker reported physical and mental health outcomes (Table 3).

Back pain was associated with increased workload stress (OR 1.52, CI 1.29-1.79), stress due to

conflict with other health professionals and lack of recognition (OR 1.72, CI 1.40-2.11), and frequent

verbal aggression by residents towards care workers (OR 1.36, CI 1.06-1.74), and inversely

associated with staffing adequacy (OR 0.69, CI 0.56-0.84), lack of job preparation (OR 0.70, CI 0.57-

0.85), and all age groups (31 to 40 years: OR 0.70, CI 0.51-0.97; 41-50 years: OR 0.54, CI 0.38-

0.77; older than 50 years: OR 0.46, CI 0.33-0.66). Joint pain was associated with increased

perceptions of workload (OR 1.57, CI 1.28-1.92), conflict with other health professionals and

recognition stress (OR 2.06, CI 1.62-2.63), frequent verbal aggression by residents (OR 1.50, CI

1.12-2.02), care workers older than 50 years (OR 1.93, CI 1.28-2.91), and inversely associated with

perceived staffing adequacy (OR 0.75, CI 0.58-0.95). There were no significant associations between

the psychosocial work environmental factors and age groups measured and needle stick injuries or

work-related allergies.

We also found several associations between the psychosocial work environment, and age

groups and mental health outcomes. Sleeplessness was associated with increased workload stress

(OR 1.52, CI 1.26-1.84), conflict with other health professionals and lack of recognition stress (OR

1.92, CI 1.52-2.41), and care workers older than 50 years (OR 1.52, CI 1.03-2.24). Tiredness was

associated with increased workload stress (OR 2.11, CI 1.74-2.58) and conflict with other health

professionals and lack of recognition stress (OR 2.06, CI 1.66-2.55), and was inversely associated

with perceptions of staffing adequacy (OR 0.68, CI 0.54-0.86), self-reported autonomy (OR 0.66, CI

0.50-0.87), and care workers older than 40 years (41-50: OR 0.44, CI 0.30-0.65; older than 50: OR

0.37, CI 0.23-0.57). Headache was associated with increased workload stress (OR 1.27, CI 1.04-

1.55) and conflict with other health professionals and lack of recognition stress (OR 2.11, CI 1.65-

2.70), and inversely associated with collaboration with the nursing director (OR 0.68, CI 0.47-0.99),

and care workers older than 40 years (41-50: OR 0.55, CI 0.36-0.86; older than 50: OR 0.42, CI

0.27-0.66). Emotional exhaustion was associated with increased workload stress (OR 1.96, CI 1.65-

2.34), lack of job preparation stress (OR 1.41, CI 1.14-1.73), and conflict and lack of recognition

stress (OR 1.68, CI 1.37-2.06), and was inversely associated with care workers’ perceptions about

leadership (OR 0.70, CI 0.56-0.87), and care workers of all age groups (31-40: 0.65, CI 0.48-0.89;

41-50: OR 0.55, CI 0.40-0.76; older than 50: OR 0.58, CI 0.41-0.81).

54

Table 3. Associations between age, work environment and mental and physical health outcomes♱

Explanatory variables Physical health outcomes

Back pain

OR (95%CI)

Joint pain

OR (95%CI)

Needle stick injuries

OR (95%CI)

Allergies

OR (95%CI)

1Age groups (years)

! 31-40

! 41-50

! >50

0.70 (0.51-0.97)*

0.54 (0.38-0.77)**

0.46 (0.33-0.66)**

1.19 (0.78-1.81)

1.41 (0.93-2.15)

1.93 (1.28-2.91)**

1.27 (0.51-3.13)

1.06 (0.39-2.87)

0.89 (0.37-2.16)

2.59 (0.76-8.86)

0.75 (0.18-3.10)

0.47 (0.10-1.24)

Psychosocial work environment

Leadership 1.11(0.87-1.42) 1.11(0.84-1.46) 0.68(0.38-1.22) 0.42(0.14-1.31)

Work stressors

! Workload

! Lack of job preparation

! Conflict & lack of recognition

! Percentage of residents with dementia

1.52(1.29-1.79)**

0.70(0.57-0.85)**

1.72(1.40-2.11)**

0.99(0.99-1.0)

1.57(1.28-1.92)**

0.91(0.71-1.16)

2.06(1.62-2.63)**

0.99(0.99-1.0)

0.77(0.51-1.16)

1.66(0.97-2.85)

1.36(0.81-2.30)

1.00(0.99-1.02)

1.33(0.69-2.56)

1.61(0.83-3.10)

2.01(0.94-4.33)

0.99(0.97-1.01)

Staffing adequacy

0.69(0.56-0.84)** 0.75(0.58-0.95)* 0.66(0.40-1.10) 1.06(0.48-2.33)

55


! Verbal Aggression

Physical Aggression

1.36(1.06-1.74)*

1.02(0.74-1.40)

1.50(1.12-2.02)**

0.91(0.64-1.33)

0.99(0.48-2.08)

0.91(0.33-2.53)

2.17(0.94-5.0)

0.47(0.15-1.46)

3Participation in decision making

1.11(0.79-1.58)

1.30(0.91-1.86)

1.30(0.57-2.94)

1.99(0.60-6.55)

4Collaboration

! Nursing Director

! Colleagues

0.90(0.66-1.23)

1.25(0.78-1.99)

0.80(0.57-1.13)

1.73(0.95-3.13)

1.23(0.53-2.85)

1.27(0.40-4.09)

1.56(0.48-5.10)

0.94(0.21-4.05)

3Autonomy 0.97(0.74-1.26) 1.10(0.81-1.44) 1.18(0.65-2.12) 0.75(0.38-1.46)

Explanatory variables Mental health outcomes

Sleeplessness

OR (95%CI)

Tiredness

OR (95%CI)

Headache

OR (95%CI)

Emotional Exhaustion

OR (95%CI) 1Age groups (years)

! 31-40

! 41-50

! >50

0.84 (0.55-1.30)

1.02 (0.67-1.56)

1.52 (1.03-2.24)*

0.67 (0.43-1.04)

0.44 (0.30-0.65)**

0.37 (0.23-0.57)**

1.08 (0.71-1.66)

0.55 (0.36-0.86)**

0.42 (0.27-0.66)**

0.65 (0.48-0-89)**

0.55 (0.40-0.76)**

0.58 (0.41-0.81)**


Leadership 0.75(0.56-1.0) 1.12(0.84-1.49) 1.04(0.79-1.40) 0.70(0.56-0.87)**

56

♱Multiple regression models included all variables. The adjusted models were controlled for facility characteristics (language region, profit status, size) and care worker characteristics (gender, nursing job category, overtime frequency, employment percentage, professional experience in nursing in years, & shift work). 1Age groups (years): 1=18 to 30; 2=31 to 40; 3=41 to 50; 4= older than 50. Groups 2, 3 and 4 are reported in comparison to group “1”. 2Workplace violence: 0=never, less than once a week, approximately once a week; 1= several times a week, daily, several times a day; 3Participation& autonomy: 0=strongly disagree, slightly disagree, 1=slightly agree, strongly agree; 4collaboration: 0=very low, rather low; 1=rather high, very high; 2=Don’t know. Group “1” is reported in comparison to group “0” (reference group). *p-value<0.05; **p<0.01

Work stressors

! Workload

! Lack of job preparation

! Conflict & lack of recognition

! Percentage of residents with dementia

1.52(1.56-1.84)**

0.98(0.78-1.22)

1.92(1.52-2.41)**

0.99(0.99-1.0)

2.11(1.74-2.58)**

0.8(0.64-1.0)

2.06(1.66-2.55)**

0.99(0.99-1.00)

1.27(1.04-1.55)*

0.87(0.68-1.11)

2.11(1.65-2.70)**

0.99(0.99-1.0)

1.96(1.65-2.34)**

1.41(1.14-1.73)**

1.68(1.37-2.06)**

1.00(0.99-1.01)

Staffing adequacy 0.92(0.73-1.17) 0.68(0.54-0.86)** 0.86(0.65-1.14) 0.84(0.68-1.03)


! Verbal Aggression

! Physical Aggression

!

1.27(0.94-1.72)

1.28(0.87-1.87)

1.03(0.77-1.37)

0.97(0.64-1.47)

0.98(0.67-1.37)

1.14(0.77-1.71)

1.24(0.97-1.60)

1.05(0.75-1.47)

3Participation in decision making 0.98(0.69-1.39) 1.31(0.89-1.95) 1.18(0.78-1.79) 1.30(0.94-1.80)

4Collaboration

! Nursing Director

! Colleagues

0.79(0.55-1.14)

0.65(0.41-1.04)

0.73(0.51-1.04)

0.96(0.57-1.62)

0.68(0.47-0.99)*

1.67(0.89-3.14)

0.99(0.74-1.34)

1.22(0.76-1.97) 3Autonomy 0.92(0.70-1.21) 0.66(0.50-0.87)** 0.95(0.68-1.31) 0.93(0.72-1.20)

57

2.6 Discussion

This Swiss nursing home study reports on compromised physical and mental health

outcomes among professional care workers in relation to selected psychosocial work environment

factors. The most prevalent physical and mental outcomes were back pain and joint pain, and

emotional exhaustion, tiredness, sleeplessness, and headache. Along with age, the psychosocial

work environment factors such as work stressors and staffing adequacy showed a relationship with

the physical and mental health care worker outcomes measured. Other factors that may be

perceived as potential risk factors (e.g. percentage of residents with dementia, physical violence) or

potential protective factors (e.g. participation in decision making) were not associated with the health

of care worker outcomes examined.

The study findings about back pain and joint pain confirmed that musculoskeletal injuries

rank high in nursing homes, in agreement with previous studies [11-13, 40]. In nursing homes, older

people depend on the care provider to meet their daily needs such as bathing, toileting, eating, lifting,

repositioning, and transferring [41]. The low prevalence rate of work-related allergies, including

dermatitis, was inconsistent with a European study which revealed skin diseases are a prevalent

problem in nursing homes [20], but confirmed results from a study conducted in Southern Taiwan

[21] where dermatitis occurred less frequently in nursing home care workers. Although we found

relatively few needle stick injuries they could still pose a serious hazard for nursing home care

workers [22]. Furthermore, evidence showed that care workers underreport needle stick injuries [42]

due to either lack of time [43] or due to their belief that needles were not contaminated [22]. We

speculate that care workers may have underestimated both needle stick injuries and skin allergies.

However, our assumption warrants further research for validation.

In addition to physical health, our study examined adverse mental health outcomes and

showed that nearly one fourth of our sample reported emotional exhaustion, and between 10% and

14% tiredness, sleeplessness, and headaches, which is in line with other study findings [23, 26, 44].

It might appear plausible that the intensive nature of the labour and resident care in nursing homes

can place care workers at risk of general fatigue, headaches, emotional and social dysfunction, and

sleeplessness [44].

Psychosocial work environment factors showed an association with physical health

outcomes. Specifically, high workload stress, conflict with other health professionals and lack of

recognition stress, and perceptions of inadequate staffing were associated with back pain and joint

pain. Consistent with our findings, in another study, care workers who experienced high workload

were exposed to major risks for musculoskeletal injuries [11]. Some daily work processes that might

explain include care workers experiencing conflict with colleagues, time pressure, and increased

mechanical workload to meet resident care demands, which could increase awkward posturing and

repetitive movement at work [45].

58

Verbal aggression of nursing homes residents towards care workers was also associated

with back pain and joint pain, in agreement with a recent study [46]. Despite limited research

investigating the association between workplace residents’ verbal aggressiveness and physical

injuries, there is some evidence showing that musculoskeletal pain/inflammation are more common

among care workers exposed to verbal violence [46]. Other studies reported that verbal aggression

against care workers can provoke considerable stress [46, 47]. A possible explanation for the

association between verbal aggression and physical injuries is a muscle tension [46]. Our study

precludes making any causal inferences in this regard, but indicates the need for further exploration.

Counter intuitively, we found that stress related to poor preparation for the job was

associated with reduced self-reported back pain. A plausible explanation might be that those who

have not received appropriate training in ergonomics might have low self-confidence in their skills,

which may explain their lack of involvement in strain producing tasks, compared to those prepared.

Yet, further investigation is necessary to validate these results, as no previous studies have

examined this relationship to our knowledge.

Previous studies on geriatric care workers [48] found that the prevalence of back pain and

other musculoskeletal pain increased with age, which was confirmed in our study for joint pain but

not back pain. Contradictory results for the effect of age on care workers` health also exist and

suggest that age is a poor predictor for back pain [49]. A plausible explanation of this inconsistency

could be either that those who suffer from back pain tend to leave their work, or that care workers

with older age have accumulated ergonomic skills, which protect them from back pain. This

interpretation warrants further investigation.

Moreover, our findings suggested an association between stress related to workload and

conflict with other health professionals and lack of recognition and mental health outcomes

(sleeplessness, tiredness, headache, and emotional exhaustion). In addition, perceptions of greater

staffing adequacy were associated with reduced odds of reporting tiredness. Similarly, while

perceptions of strong leadership were associated with low-reported emotional exhaustion, high

autonomy at work was associated with lower odds of reporting tiredness, and high collaboration with

the nursing director was associated with lower odds of headache. In alignment with our findings,

earlier studies have found that exposure to work stressors, including high workload and high job

demands [27, 50, 51], lack of coworker [27, 51] and management [27] support, and low job autonomy

[27, 51] were associated with poor mental health outcomes. This imbalance can be explained by

Cannon`s Stress Theory [52], where prolonged exposure to stressors induce a disruptive biological

system with the disruption preventing coping with changes, resulting in poor mental health outcomes

such as sleeplessness, fatigue, headaches, and social and emotional dysfunction [44].

We also found that stress due to lack of job preparation was associated with an increased

likelihood of reporting emotional exhaustion. Previous research has shown that on-the-job training

59

and mastery of skills can help manage demanding situations [53]. However, the reason for this

finding in relation to reports of emotional exhaustion in our sample is unclear.

Finally, results showed that age is correlated to mental health outcomes. Sleeplessness was

positively related to age, which may be explained by the slow down of the circadian rhythm with

increased age, causing sleeping disorders [54]. However, tiredness, headache and emotional

exhaustion were inversely related to increased age, which was supported by a previous US study on

nursing mental health [55]. This may reflect the fact that older care workers have built confidence and

professional skills that help them deal with difficult situations at work.

2.7 Strengths and limitations

The SHURP study is the first national representative survey to comprehensively survey

health of care workers in Swiss nursing homes and to comprehensively examine the association

between different factors of their work environment and physical and mental health outcomes. The

findings of this study should, however, be interpreted in light of some limitations. First, the cross-

sectional design did not allow us to make causal inferences about the relationships that were found.

Nevertheless, our findings will inform stakeholders and future prospective studies about system

factors associated with care workers health outcomes. Second, the secondary data analysis limited

our ability to fully evaluate the impact of all domains of the proposed model (cf. Figure 1) on care

workers` health. Third, the outcome variables used in this study were exclusively self-reported, which

could be a source of bias. Yet, self-reported care workers’ perception of health has been shown

empirically to be a good indicator of health status [56]. For future research, the collection of more

objective data or observer reported data are recommended, such as observation or medical

examination of the physical and mental health of care workers. Fourth, the lack of a comparison

group from the normal population does not allow contextual interpretation of the health findings.

Finally, our cross sectional study prevented us from tracking care workers who have left their nursing

home workplace due to worse health conditions, which may have led to an underestimation of

reported poor care workers` health.

2.7 Conclusions

In conclusion, along with age, poor psychosocial work environmental factors in nursing

homes were related to the physical and mental health of care workers. Modifying psychosocial work

environment factors in Swiss nursing homes is a promising strategy to improve the health of their

care workers. Longitudinal studies are needed to conduct targeted assessments of care workers

health status, taking into account their age, along with the exposure to all four domains of the

proposed model.

60

2.8 Funding/ Potential competing interests

No conflicts of interest declared. The Swiss Health Observatory, the Nursing Science

Foundation Switzerland, the University of Basel Research fund 2012, and the Swiss Alzheimer

Association funded The SHURP study. Additionally, the PhD Program in Health Sciences, University

of Basel had granted the Start Stipend Award.

2.9 Acknowledgements

Special thank goes to Professor Sandra Engberg, School of Nursing, University of Pittsburgh

for her critical review of the manuscript, many helpful comments and editing.

61

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65

CHAPTER 3

ABSENTEEISM AND PRESENTEEISM AMONG CARE WORKERS

IN SWISS NURSING HOMES AND THEIR ASSOCIATION WITH

PSYCHOSOCIAL WORK ENVIRONMENT: A MULTISITE CROSS-

SECTIONAL STUDY

Suzanne R. Dhaini¹ MA, Franziska Zúñiga 1 PhD, Dietmar Ausserhofer1, 2 PhD, Michael Simon1,3 PhD,

Regina Kunz4 MD, Sabina De Geest¹ PhD, Rene Schwendimann1 PhD

1Institute of Nursing Science, University of Basel, Switzerland

2Claudiana, University of Applied Science, Bolzano (BZ), Italy

3 University Hospital Inselspital Bern, Nursing & Midwifery Research Unit, Switzerland

4 Swiss Academy of Insurance Medicine, University Hospital Basel, Basel, Switzerland

Published in the Gerontology, [online first] October 2015. DOI: 10.1159/000442088

66

3.1 Abstract

Background: Worker productivity is central to the success of an organization such as health

care institutions. However, both absenteeism and presenteeism impair that productivity. While

various hospital studies have examined the prevalence of presenteeism and absenteeism and its

associated factors among care workers, evidence from nursing home settings is scarce.

Objective: To explore care workers’ self-reported absenteeism and presenteeism in relation

to nursing homes’ psychosocial work environment factors.

Methods: A cross-sectional study utilized survey data of 3,176 professional care workers in

162 Swiss nursing homes collected between May 2012 and April 2013. A GEE ordinal logistic

regression model was used to explore associations between psychosocial work environment factors

(leadership, staffing resources, work stressors, affective organizational commitment, collaboration

with colleagues and supervisor, support from other personnel, job satisfaction, job autonomy) and

self-reported absenteeism and presenteeism.

Results: Absenteeism and presenteeism were observed in 15.6% and 32.9% of care

workers, respectively. While absenteeism showed no relationship with the work environment, low

presenteeism correlated with high leadership ratings (OR 1.22, CI 1.01-1.48) and adequate staffing

resources (OR 1.18, CI 1.02-1.38).

Conclusion: Self-reported presenteeism is more common than absenteeism in Swiss

nursing homes, and leadership and staffing resource adequacy are significantly associated with

presenteeism, but not with absenteeism.

67

3.2 Introduction

Worker productivity is central to the success of any organization [1]. However, both

absenteeism, i.e., missing shifts because of feeling unwell or unfit to work, and presenteeism, i.e.,

working despite feeling unwell or unfit to work, impair that productivity. With absenteeism, as

employees contribute nothing to the organization’s operation, productivity loss per absent employee

is 100% [2]. Presenteeism is considered the opposite of absenteeism [3] but it decreases productivity

making illness at work a costly affair [1, 4]. The two concepts are closely linked: frequent

presenteeism is associated with subsequent long-term absenteeism [5].

The concept of presenteeism first appeared in empirical literature in the 1990s, [6] when

employers noticed that not only absenteeism but also presenteeism drains productivity [7]. Since

then, studies on the general population have indicated that both absenteeism and presenteeism are

strong predictors of future poor health, physical complaints, low mental well-being, and low work

ability [8].

In healthcare, previous studies have shown that high rates of presenteeism are common

among nursing care workers, regardless of their work setting [9-11]. For example, in 2011, 49% of

the Swedish public health sector workers (including hospitals and primary care workers) reported

frequent presenteeism in the preceding year [12].

Research [9, 11, 13] has suggested that the ability to work through illness depends on work

demands, workload, and perceived job stress. Hence, if the ill person perceives that co-workers will

not be able to compensate for their absence, they commonly work despite illness [9, 13]. For

example, care workers’ daily responsibilities involve providing service and responding to patients’

needs. If the ill persons perceive that the care workers present will not be able to compensate for

their absence, they commonly work despite illness [9, 14]. In nursing homes, residents who can no

longer reliably perform the basic activities of daily living in their homes require 24/7 direct care. As a

result, nursing home care workers need to perform many physically and emotionally straining

activities that risk compromising their health [15].

Several studies on the general population have indicated relationships between absenteeism

and presenteeism [13, 16]. Workers who reported calling in sick also tended to report working while

ill [13]. Individual characteristics such as occupation and gender [10], and work related factors

including a strong commitment to work [13] were found to influence both absenteeism and

presenteeism [17]. Recent studies have linked negative perceptions of the work environment [18] –

e.g., poor collaboration with colleagues [19] and time pressure [13, 20] with presenteeism. In a

Scandinavian study on the care of older people, researchers showed that high presenteeism was

associated with high workloads and elevated time pressure [11].

Compared to absenteeism, presenteeism has been relatively less researched, probably

because it is harder to track associated cost [21]. Nonetheless, existing studies have highlighted the

68

magnitude of presenteeism not only by its cost of lost productivity, but also by negatively affecting

quality patient care [21]. While various hospital studies in Europe and the U.S. have examined the

prevalence of presenteeism (ranging from 21.9% to 62%), and its associating factors [14, 19, 21],

evidence from nursing home settings is scarce. Although the relationships between absenteeism and

presenteeism are unclear, Kristensen argued convincingly that both behaviours are outcomes of the

same decision process [22]. Therefore, examining risk factors for absenteeism in nursing home care

workers’ psychosocial work environments (e.g., leadership, collaboration with supervisor, work

stressors, staffing resources) could improve our perception of presenteeism [13]. This study adds to

the body of knowledge on absenteeism, and to the growing literature on presenteesim in healthcare.

3.3 Theoretical background

The WHO Healthy Workplace Model (figure 1) [1] and its “Business Case” framework (figure

2) [1] contribute to the understanding of the work environment’s relationships with absenteeism and

presenteeism. All workplaces require healthy workers to sustain the organization [1]. Therefore, the

WHO model ties unhealthy and unsafe workplaces to work-related physical and mental illnesses,

very likely increasing the risks of both absenteeism and presenteeism. The WHO’s key components

of a healthy workplace correspond to four domains: 1) the physical work environment (e.g. chemical

hazards and biological hazards); 2) the psychosocial work environment (e. g organization daily

practices and workplace stressors); 3) personal health resources (e.g. physical inactivity from long

working hours, poor diet due to lack of time); and 4) enterprise community involvement (e.g.

supporting community screening and treatment, providing leadership and expertise related to

workplace health and safety to other organizations). Using data from the Swiss Nursing Homes

Human Resources Project (SHURP), we explored psychosocial work environment factors’

associations with absenteeism and presenteeism in nursing home care workers. Rooted in

organizational culture and daily practice, these factors can include, among others, work stressors,

staffing resource inadequacy, poor leadership, poor co-worker support, poor collaboration with

management or among colleagues, low job autonomy, low job satisfaction, and poor affective

organizational commitment [1]. The variables are defined by the WHO model but operationalized to

meet the study purposes.

69

Figure 1. The WHO Model of Healthy Workplace (own figure). Adopted from Borton (2010) [1].

70

Figure 2. The WHO conceptual framework for business case, adopted from Burton (2010) [1].

Unhealthy and unsafe work

environment domains

1-Psychosocial ψ

2-Physical

3-Personal health resources

4- Enterprise community involvement

Care workers` health

-Physical*

-Mental*

Care workers` outcomes

- Absenteeism

- Presenteeism

- A

- P-P

-M

ψ Explanatory variables

*Control variables

71

Exploring absenteeism and presenteeism in nursing homes serves two important purposes.

First, determining the prevalence of each provides insight into their magnitude as nursing workforce

outcomes in long-term care settings. Second, as work environment factors can influence employee

productivity–via absenteeism and presenteeism–they also influence an organization’s sustainability

[1]. Accordingly, this study had two aims: 1) to determine the prevalence of absenteeism and

presenteeism among professional care workers in Swiss nursing homes; and 2) to explore

psychosocial work environment factors’ associations with absenteeism and presenteeism.

3.4 Methods


This is a secondary data analysis of the multi-center, cross-sectional SHURP study, which

included a random sample of 162 nursing homes across Switzerland, stratified according to language

region and size. Nursing homes smaller than 20 beds, residential care homes, and rehabilitation

clinics for geriatric patients were excluded. Full details of the sampling and survey methods used are

provided elsewhere [23].

In the parent study, 6,947 questionnaires were distributed to care workers, of which 5,323

(76.6%) were returned. Care workers of all educational levels (registered nurses, licenced practical

nurses, certified nursing assistants, and nurse aides) who provided direct care to the nursing home

residents were invited to complete the questionnaire survey. Care workers who worked fewer than 8

hours weekly, had been employed less than 1 month on the unit, or were students were excluded

from the parent study. In the current study, only care workers without leadership positions were

included, leading to a sub-sample of 3,176 professional care workers.


Socio-demographic and professional data on care workers, including their perceptions of

their work environment, work stressors, health status, absenteeism, and presenteeism, were

collected using the SHURP study’s Care Worker Personnel Questionnaire. Nursing home facility

characteristics were captured from the SHURP Facility Profile.

The SHURP study team established the content validity of each scale used, testing the

relevance of each variable and scale separately and adjusting them as necessary until all achieved

desirable item content validity index (I-CVI) or scale content validity index (S-CVI) ratings.

All items of the care worker questionnaire were translated into German, French, and Italian.

Items were verified with the original language version by comparison of its back translation. Then,

they were tested for relevance with gerontological experts in the field to check content validity, and

72

pre-tested for their comprehensibility with end-user focus group. Further information related to the

development of the questionnaire and the survey validity pre-testing are described elsewhere [23].

3.4.3 Variables and measurements

The current study used the following dependent, independent and control variables.

Dependent Variables

Absenteeism

Absenteeism was measured via an investigator-developed item measuring how many days

(if any) in the previous 4 weeks care workers had not attended work due to feeling ill and unfit for

work. Respondents answered by number of days. Numbers were later grouped into three categories

(0=0 days, 1=1-2 days, 2=3 or more days) as in presenteeism [10].

Presenteeism

Presenteeism was measured via an investigator-developed item measuring how many days (if

any) in the previous 4 weeks care workers had attended work in spite of feeling ill and unfit for work.

Respondents answered by number of days. Answers were later grouped into three categories (0=0

days, 1=1-2 days, 2=3 or more days)[10].

Independent Variables

Psychosocial work environment risk factors

Care workers’ perceptions of their nursing homes’ leadership and staffing adequacy were

measured via items from two subscales of the Practice Environment Scale of the Nursing Work Index

(PES-NWI) questionnaire: “Nurse manager ability, leadership, and support of care workers”

(Cronbach alpha 0.84) and “Staffing and resources adequacy” (Cronbach alpha 0.74)[24]. These

were adapted for nursing home use with 4-point Likert-type scale (1=strongly disagree, 2=rather

disagree, 3=rather agree, 4=strongly agree). The leadership items asked about the extent to which

respondents perceived their unit supervisors as supportive and competent leaders, mistakes were

used as learning opportunities, care workers were rewarded or otherwise recognized for work well

done, and the unit leaders supported them in decision making. Items on staffing adequacy asked

about perception of enough staff on duty to complete all necessary work, to provide quality care, and

to discuss resident problems.

73

Work stressor items were selected from the Health Professions Stress Inventory (HPSI) [25,

26] to measure the frequency of several work-related stressors. These were measured via a 5-point

Likert-type scale (0=never, 1=seldom, 2=sometimes, 3=often, 4=very often). The instrument was

reduced from 30 to 12 items in order to reduce the SHURP`s survey burden (time spent filling out

questionnaires). The reduction was based on the ratings of experts from the gerontological field

(holding at least a Certificate of Advanced Studies up to a Master’s degree with experience in nursing

home care) with regards to the relevance of each question. The SHURP team asked the experts to

rate each item for its understandability for nursing home personnel (yes/no), and for its relevance

concerning resident safety on a 4-point scale (1=not relevant, 2=somewhat relevant, 3=quite

relevant, 4=very relevant). The item content validity index (I-CVI) was calculated for each item as

percentage of experts who rated it 3 or 4. The average scale content validity (S-CVI/Ave) was

calculated as the mean of all I-CVI. The SHURP group’s psychometric analysis of the remaining 12

items produced 3 sub-scales tested for internal consistency (Cronbach`s alpha) and measuring

stress-producing factors: (1) workload (Cronbach’s alpha: 0.73), (2) lack of job preparation

(Cronbach’s alpha 0.63), and (3) conflict and lack of recognition (Cronbach’s alpha 0.76). Stress due

to workload was measured via three items on dealing with difficult situations, having too much work

to do, and being understaffed. The three items measuring stress due to lack of job preparation asked

about fear of making mistakes, being overwhelmed when caring for terminally ill residents, and not

being prepared to meet the residents’ needs. Regarding conflict and lack of recognition, six items

asked about disagreements with other professionals, conflicts with superiors, lack of information, not

being asked about one’s opinion, being underpaid, and underuse of skills.

Affective organizational commitment was adopted from the “Questionnaire for the

Assessment of Affective, Costing, and Normative Commitment to the Organization, the

Profession/Activity and Employment Form” (COBB)[27], using five items from the Affective

Commitment sub-scale (Cronbach`s alpha 0.86), and rated on a 5-point Likert-type scale (1=strongly

disagree, 2=slightly disagree, 3=neutral, 4=slightly agree, 5=strongly agree). These items assessed

respondents’ feelings about the organizations employing them, including how happy they would be to

spend the next years with their current organization, the strength of their sense of belonging to that

organization, their level of emotional attachment to their organization, and how well their personal

ideals fit with those of the organization.

Items on collaboration with colleagues and with unit supervisors were adopted from the

Safety Attitude Questionnaire (SAQ)[28]. On 4-point Likert-type scales, respondents rated the quality

of each level of collaboration (1=very low, 2=rather low, 3=rather high, 4=very high). A “don’t know”

option was also provided (treated as missing in the analysis). For conformity with the study’s data on

risk factors, answers were dichotomized (0=very low, rather low; 1=rather high, very high). One item

on support from other personnel to care for residents was also selected from the SAQ and rated on a

74

5-point Likert-type scale (1=strongly disagree, 2=slightly disagree, 3=neutral, 4=slightly agree,

5=strongly agree). This also included the “don’t know” answer option. As above, answers were

dichotomized for data conformity (0= strongly disagree, slightly disagree, neutral; 1=slightly agree,

strongly agree).

To measure autonomy at work, a single investigator-developed item asked care workers to

rate the extent to which they decided independently how to perform their work. This item was rated

on a 4-point Likert-type scale (1=strongly disagree, 2=slightly disagree, 3=slightly agree, 4=strongly

agree). Again, responses were dichotomized (0=strongly disagree, slightly disagree; 1= slightly

agree, strongly agree). Job satisfaction was measured via another investigator-developed item. On a

4-point Likert-type scale (1=very dissatisfied, 2=rather dissatisfied, 3=rather satisfied, 4=very

satisfied), this assessed each care worker’s overall satisfaction with his/her current job in the nursing

home. As above, answers were dichotomized as positive or negative (0=very dissatisfied, rather

dissatisfied; 1=rather satisfied, very satisfied).

Control Variables

Facility characteristics

Facility characteristics included size (small: 20-49 beds; medium: 50-99 beds; or large: ≥100

beds), language region (German-, French-, or Italian-speaking area), and ownership status (private,

private subsidized, public).

Care worker socio-demographic and professional characteristics

Care worker socio-demographic data were collected on age (date of birth), gender,

educational level (i.e., registered nurse, licensed practical nurse, certified nursing assistant, nurses

aide), professional experience in nursing in years (number of years in nursing), percentage of full-

time employment (corresponding to number of hours worked per week, ranging from 20%

(8hrs/week) to 100% (42hrs/week)), agency staff (i.e., a temporary (vs. permanent) position), usual

work shifts (days, evenings, nights, or regularly rotating shifts), and frequency of overtime (less

frequently, every 5-7 working days, every 2-4 working days, almost every shift). Age (up to 30 years;

31-40; 41-50; >50 years) and professional experience in nursing (up to 5 years; 6-10 years; 11-15

years; 16-20 years; >20 years) were then categorized for analysis purposes. Professional categories

were based on 5 nursing education levels: registered nurses (three to six years of education, leading

to a diploma in nursing, bachelor’s degree (BSc.N. or equivalent) or higher); licensed practical nurses

(LPN) (three years of education); certified nursing assistants (CNA) (two years of education); and

nurse aides (short courses or on-the-job training).

75

Care worker health status

Care workers’ physical health status was assessed using a health index designed to

minimize the number of health-related outcome variables. Five items were selected from the Swiss

Health Survey [29] to gather self-reported data on back pain, joint pain, tiredness, sleeplessness, and

headache during the preceding 4 weeks, with each measured on a 3-point Likert-type scale (1=not at

all, 2=a little bit, 3=strongly). The index score was calculated as sum of item scores (range: 5-15)

over number of items (n=5) minus 5 (allowing the index to start with 0 for “no health complaints”).

Higher index scores (max: 10) signify more health problems. This index is based on principal

component analysis of the 5 items, with one factor explaining 45% of the variance. Item loadings

ranged between 0.62 and 0.74 (Cronbach`s alpha 0.69).

The care worker`s mental health status-emotional exhaustion–was measured on a 7-point

Likert-type scale (ranging from 0=never, to 6=daily) using the item “feeling exhausted from work”

from the Maslach Burnout Inventory (MBI)[30]. The validity of measuring emotional exhaustion with a

single item is described elsewhere [31].

3.4.4 Data collection and Analysis

The SHURP survey was administered between May 2012 and April 2013. Detailed

information on data collection is provided elsewhere [23].

As facility and care worker characteristics, including health status, have been extensively

investigated in previous studies, showing positive relationships with absenteeism and presenteeism,

they were used here as control variables [19, 32]. To address aim 1, we calculated descriptive

statistics (frequencies, percentages, means, and standard deviations). For aim 2, we first analyzed

the univariate associations between facility and care worker characteristics (including health status)

and absenteeism and presenteeism. We used generalized estimation equation (GEE) multiple

regression models to account for the clustering of care workers in nursing home units. Next,

adjusting for facility characteristics and care worker characteristics (including health status), we used

ordinal logistic GEE regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for

psychosocial work environment risk factors. We also assessed multi-collinearity of all work

environment factors with variance inflation factor (VIF). Based on this VIF with all values remaining

below the threshold of 5, all variables were included in the analysis[33]. Missing values analysis

showed less than 5% of responses missing per variable, with approximately 23% of respondents

(n=938) omitting one or more responses. To explore any pattern of missed data, we analysed the

sensitivity of the entire sample (n=4,014) against that of the subgroup who submitted complete

response sets (n=3,176). To compare means of each variable examined in this study, we calculated

Cohen’s d. Calculated differences were small (Cohen’s d<0.2)[34], with similar inferences. All data

76

analyses were conducted using IBM/SPSS for Mac Statistics 21.0. We report only adjusted results of

our analysis.

3.4.5 Ethical approval

All participating nursing home administrators and nursing directors gave written informed

consent to participate in the SHURP study. Care workers’ voluntary and confidential return of their

SHURP questionnaires was treated as informed consent. This study was covered by the Swiss

nursing homes human resources Project (SHURP), for which the ethic committee of the state of

‘Beider Basel’ (Ref. Nr. EK:02/12) granted approval.

3.5. Results


Overall, this study included data supplied by 3’176 care workers in 162 nursing homes.

Slightly fewer than half of participating nursing homes were medium in size (46.3%); one third had

public ownership (37%). Three-quarters (75.9%) were located in Switzerland’s German-speaking

area. Table 1 summarizes the participants’ characteristics and psychosocial work environment

factors. Across all facilities, a large majority (92.2%) of care workers were female; fewer than a third

were registered nurses (27.9%). Roughly a third (32.7%) were 50 years of age or older and roughly a

quarter (24.6%) had 21 or more years of nursing experience. The majority (75.3%) were employed

more than 50% and not working for an agency (93.7%). Fewer than half (44.7%) reported working

mostly day shifts. Slightly more than a third (37.7%) reported incidences of work-related emotional

exhaustion ranging from several times a month to daily. Overall, respondents reported positive

psychosocial work environments, with high levels of collaboration both among colleagues (96.0%)

and with unit supervisors (90.6%), strong levels of support from other personnel (88.8%), autonomy

at work (81.1%), and job satisfaction (87.5%).

77

Table 1. Facility and care worker characteristics and psychosocial work environment factors

Facility characteristics n (%) Means (SD)


German

French

Italian

123 (75.9)

30 (18.5)

9 (5.6)

Profit status

Public

Private subsidized

Private

60 (37.0)

43 (26.5)

59 (36.4)

Nursing home size

Small (20-49beds)

Medium (50-99 beds)

Large (≥100 beds)

63 (38.9)

75 (46.3)

24 (14.8)

Care worker characteristics

Gender

Male

Female

248 (7.8)

2928 (92.2)

Age groups (years)

Up to 30

31-40

41-50

>50

680 (21.4)

578 (18.2)

878 (27.6)

1040 (32.7)

Professional category

Registered Nurse

Licensed practical nurse

Certified nursing assistant

Nurse Aide

887(27.9)

744 (23.4)

613 (19.3)

932 (29.3)

78

Employment percentage

Up to 50%

>50%

784 (24.7)

2392 (75.3)

Agency Staff

Yes

No

201 (6.3)

2975 (93.7)

Experience in nursing (years)

Up to 5

5 to 10

11 to 15

16 to 20

>20

660 (20.8)

731 (23.0)

593 (18.7)

412 (13.0)

780 (24.6)

Usual shift

Days only

Evenings only

Nights only

Regular change of shifts

1421 (44.7)

198 (6.2)

391 (12.3)

1166 (36.7)

Overtime frequency

Less frequently



Almost every shift

2423(76.3)

251 (7.9)

443 (13.9)

59 (1.9)

Care workers reported health status

Emotional Exhaustion

Never, several times a year or less, once a month

or less,

Several times a month, once a week, several times

a week, daily

1978 (62.3)

1198 (37.7)

Health Index1 3.47 (2.24)


Leadership 3.14 (0.60)

79

1Health index included self reported back pain, joint pain, tiredness, sleeplessness, and headache during the past 4 weeks prior to the survey.

Staffing resources 2.82 (0.66)

Work Stressors

Workload

Conflict and lack of recognition

Lack of job preparation

1.54 (0.82)

0.90 (0.66)

0.67 (0.58)

Affective organizational commitment

3.84 (0.82)

Collaboration with colleagues

Very low, rather low

Rather high, very high

127 (4.0)

3049 (96.0)

Collaboration with unit supervisor

Very low, rather low


300 (9.4)

2876 (90.6)

Support from other personnel

Strongly disagree, slightly disagree, neutral

Slightly agree, strongly agree

355 (11.2)

2821 (88.8)

Autonomy

Strongly disagree, slightly disagree

Slightly agree, strongly agree

601 (18.9)

2575 (81.1)

Job satisfaction

Very dissatisfied, rather dissatisfied

Rather satisfied, very satisfied

396 (12.5)

2780 (87.5)

80

3.5.2 Prevalence of absenteeism and presenteeism among care workers

Of the 3,176 care workers who submitted eligible questionnaires, 14.6% reported

absenteeism, with 32.9% reporting presenteeism for at least one shift during the month prior to the

survey (Table 2); 5.6% reported three or more days of absenteeism; and 16.8% reported three or

more days of presenteeism. Conversely, 85.4% and 67% of all participants respectively reported

zero days of either absenteeism or presenteeism.

Table 2. Prevalence of absenteeism and presenteeism, n (%)

Care worker reported Absenteeism Presenteeism

0 days 2713 (85.4) 2129 (67.0)

1 to 2 days 285 (9.0) 512 (16.1)

≥3 days 178 (5.6) 535 (16.8)

Total of 1 and more days 463 (14.6) 1047 (32.9)

3.5.3 Associations of psychosocial work environment factors with absenteeism and presenteeism

Absenteeism showed no significant association with any psychosocial work environment

factor investigated in this study. However, presenteeism was associated with two psychosocial work

environment risk factors (Table 3): perceptions of supportive leadership (OR 1.22, CI 1.01-1.48) and

adequate staffing resources (OR 1.18, CI 1.02-1.38) both increased the odds of low presenteeism.

No other associations with psychosocial work environment factors were statistically significant.

81

Table 3. Association between work environment factors and absenteeism and presenteeism

Psychosocial work environment Absenteeism1 Presenteeism1

OR2 (95% CI) OR2 (95%CI)

Leadership 1.01 (0.78-1.31) 1.22 (1.01-1.48)*

Staffing resources 0.85 (0.69-1.04) 1.18 (1.02-1.38)*

Work Stressors

Workload

Conflict & lack of recognition

Lack of job preparation

1.03 (0.86-1.23)

0.98 (0.79-1.22)

1.13 (0.90-1.40)

1.01 (0.88-1.16)

0.85 (0.71-1.01)

0.93 (0.79-1.09)

Affective organizational commitment 1.12 (0.94-1.34) 0.90 (0.78-1.04)

3Collaboration with colleagues


1.33 (0.84-2.12)

1.06 (0.70-1.60)

3Collaboration with unit supervisor 0.88 (0.59-1.33) 0.75 (0.55-1.03)

3Support from other personnel to care for residents 0.9 (0.65-1.25) 1.02 (0.78-1.33)

82

3Autonomy at work

0.98 (0.74-1.29)

1.03 (0.84-1.26)

3Job satisfaction 1.26 (0.89-1.78) 1.17 (0.87-1.56)

1Absenteeism & presenteeism: 0=none; 1= 1 to 2 days; 2=3 & more days. The analysis models the probabilities having lower presenteeism values. 2The adjusted ordinal regression models were controlled for facility characteristics (language region, profit status, size) and care worker characteristics (gender, age, professional category, agency staff, employment percentage, experience in nursing, usual shift, overtime frequency; health status: health index, emotional exhaustion). 3Collaboration with colleagues & with supervisor: 0=very low, rather low; 1=rather high, very high; Support from other personnel: 0= strongly disagree, slightly disagree, neutral; 1=slightly agree, strongly agree; Autonomy at work: 0= strongly disagree, slightly disagree; 1= slightly agree, strongly agree; Job satisfaction:0= very dissatisfied, rather dissatisfied; 1=rather satisfied, very satisfied. Group “1” is being reported for the explanatory variable in reference to group “0”. *p-value >0.05, **p-value >0.01

83

3.6 Discussion

While this study found no significant associations between psychosocial work environment

risk factors and self-reported absenteeism, analyses indicated that both perception of supportive

leadership and staffing resource adequacy correlated with lower self-reported presenteeism. While

our findings on absenteeism do not support previous research, our measured 37% prevalence of

self-reported presenteeism [10] is congruent with earlier observations [10, 14].

Overall, nursing home care workers’ self-reported presenteeism in the month prior to the

survey was more common than similarly reported absenteeism over the same period. While the

prevalence of self-reported absenteeism of three and more days was fairly low (5.6%), it was slightly

higher than that self-reported for US healthcare workers in the same year (2012) (4.5%)[35].

Unfortunately, the US findings provided no nursing home-specific figures. Also, US healthcare

workers may not enjoy the same protections as in the Switzerland, where missing a shift may entail

losing a day`s pay.

Comparing various occupations of the general population in Sweden (e.g., care providers

and school teachers), Aronsson et al. (2000) observed higher presenteeism among female

healthcare workers compared with female workers in other occupations [10]. This supports

Szymczak, J.E., et al.’s (2015) conclusion that the nature of a caring relationship between the care

worker and the patient decreases the likelihood of absenteeism and magnifies the tendency to work

while ill [14], and John’s (2010) postulation that the work identity of the care worker is linked to

helping the vulnerable patient [36]. Recent findings in one US hospital suggested that care workers

were ambivalent both about which symptoms and illnesses constituted being too sick to work, and

about whether their organizations’ sickness relief systems were adequate [14].

As noted above, in contrast to previous studies on predictors of absenteeism in nursing

homes [37, 38], we found no association between psychosocial work environment and self-reported

absenteeism. While the perception of a supportive leadership, supportive peer relationships [37, 38],

appropriate job training, job satisfaction [38], and affective organizational commitment[39] have all

been linked to reduced rates of absenteeism in other European healthcare settings, this study

confirmed no such relationships. However, in accordance with one study [20], we found that job

satisfaction did not influence the probability of absenteeism. A plausible explanation for inconsistent

study findings would be the broad range of workplace cultures, social, legal, and economic contexts

involved. Varying from one country or culture to another, all these factors impact the traditions and

practices of healthcare workers, potentially influencing their attitudes towards absenteeism [10].

Our findings suggest that absenteeism cannot be fully explained by care workers’ work

attitudes [27, 40]. For example, personal factors such as health status have been found to predict the

probability of absenteeism [20] and influence the relationship between affective organizational

commitment and absenteeism [27].

84

One novel finding was that an increase in the perception of a supportive leadership and

adequate staffing resources ratings increased the odds of self-reported low presenteeism. This is

very possibly because care workers confident that their perception of a supportive leadership and/or

the available staffing resources are adequate to counterbalance absences are more comfortable

about staying home while ill. Our findings corroborate those of a previous study on the general

Danish workforce [13], indicating that work-related factors, e.g., high levels of time pressure and poor

social support, were predictors of presenteeism. In a much more recent study [39] using a univariate

model, affective organizational commitment was inversely related to presenteeism, which was

confirmed in our simple regression model (not shown). In our multivariate model, affective

organizational commitment lost its significance in combination with all other variables. As no previous

studies have specifically examined presenteeism in relation to care workers` perception of a

supportive leadership and staffing resource adequacy, these findings warrant further investigation.

Finally, our findings suggest that, as psychosocial work environment factors, the perception

of a supportive leadership and staffing resource adequacy are important in predicting presenteeism

but not absenteeism. Compared to absenteeism, there is no golden rule to describe whether

presenteeism is a desired or undesired behaviour in health care. In our opinion, showing up to work

while ill could be a sign of commitment as discussed earlier, and fear of loosing one`s job when being

absent too often. Nevertheless, one could also see presenteeism as a risk of poor performance due

to illness, as a sign of lost productivity [21].


The SHURP study is the first comprehensive national survey health of care workers in Swiss

nursing homes to gather data both on work environment factors and on absenteeism and

presenteeism. The findings of this secondary analysis, however, should be interpreted in light of

certain limitations. First, the definition of illness and “staffing adequacy” used in this study, relied

solely on the respondents’ subjective perceptions of their health, and staffing level, with no

independent evaluation of their objective health status and “adequacy” standards in staffing.

Second, the cross-sectional design does not allow causal inferences about the observed

relationships between variables. Nevertheless, our findings will inform stakeholders and future

interventional studies about system factors associated with care workers’ presenteeism at the levels

of the organization and the individual care worker. Third, quantifying presenteeism relied solely on

self-report measures. Fourth, the secondary data analysis limited our ability to fully evaluate the

impacts of all of the proposed model’s domains (Fig.1) on care workers’ health.

85

3.8 Conclusion

This is the first study in a representative sample of Swiss nursing homes to examine self-

reported absenteeism and presenteeism among professional care workers in relation to selected

psychosocial work environment factors. Our findings indicate that self-reported presenteeism is more

common than absenteeism in Swiss nursing homes, and that the perception of a positive leadership

and staffing resource adequacy are significant associations with presenteeism, but not absenteeism.

Care workers` presenteeism in nursing homes is an area that has been overlooked. Focusing on

presenteeism is reasonable for nurse directors and administrators who want to promote nurses`

health in order to sustain the organization. Future analysis is required to assess how presenteeism

might influence quality of care. Additional analysis is needed, taking into account the four work

environment domains of the proposed WHO workplace model.

3.9 Fund/Conflict of interest

No conflicts of interest declared. This study was funded by the Swiss Health Observatory,

Nursing Science Foundation Switzerland, University of Basel’s Research fund 2012, Swiss Alzheimer

Association, and an anonymous sponsor.


Special thank goes to the nursing homes and care workers for participating in the SHURP

study, and to Chris Shultis for editing our manuscript.

86

3.11 References



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89

CHAPTER 4

CARE WORKERS` HEALTH, PRESENTEEISM, AND IMPLICIT

RATIONING OF CARE IN NURSING HOMES: A MULTISITE

CROSS-SECTIONAL STUDY

Suzanne R. Dhaini1, MA, Franziska Zúñiga1, PhD, Dietmar Ausserhofer1,2, PhD, Michael Simon1,3,

PhD, Regina Kunz4, MD, Sabina De Geest1,5, PhD, Rene Schwendimann1, PhD

1Institute of Nursing Sciences, University of Basel, Basel, Switzerland

2Claudiana, University of Applied Science, Bozen – Bolzano (BZ), Italy

3Inselspital Bern University Hospital, Nursing & Midwifery Research Unit, Bern, Switzerland

4Swiss Academy of Insurance Medicine, University Hospital Basel, Basel, Switzerland

5Academic Center of Nursing and Midwifery, KU-Leuvin, Belgium

Submitted to the Journal of Nursing Management, January, 2016

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4.1 Abstract

Aims: To explore associations between care workers’ health and implicit rationing of care.

Background: Diverse studies have linked impaired health to reduced work performance–a factor

measured through omission of required tasks.

Methods: This cross-sectional study gathered data from 3,239 care workers in 162 Swiss nursing

homes. Data were analyzed via a linear logistic regression model using general estimating

equations.

Results: Overall, rationing of care occurred “never” to “seldom”. Rationing of activities of daily living

was positively associated with care workers’ joint pain (β 0.04, CI 0.001-0.07), emotional exhaustion

(β 0.11, CI 0.07-0.15), and presenteeism (β 0.05, CI 0.004-0.09). Rationing of caring, rehabilitation,

and monitoring was positively associated with care workers’ joint pain (β 0.05, CI 0.01-0.09) and

emotional exhaustion (β 0.2, CI 1.16-0.24).

Conclusions: Nursing home care workers’ health is strongly associated with rationing of tasks

directly related to resident care.

Implications for Nursing Management: Health organizations should be aware of the association

between health-related issues and rationing of care and consider programs to promote care workers’

health.

91

4.2 Background

Healthcare workers are frequently required to perform demanding tasks[1, 2] often under

unhealthy working conditions,[3] which can compromise care workers’ physical and mental health.[3,

4] Emphasizing the importance of a healthy workplace to organizations’ sustainability, Burton (2010)

and Neira (2010)[4, 5] defined four key workplace components that influence employee health and

safety: the physical work environment; the psychosocial work environment; personal health

resources; and enterprise community involvement. This model suggests that employees who work

through illness perform below their normal capacity, which may compromise the quality of client

service, i.e., patient care[4]. In the context of this study, work performance refers to the employee’s

cognitive performance,[6] including visuomotor, verbal, and decision-making functions.[7]

Work performance can be assessed through error and omission rates in relation to required

tasks,[6] often referred to as rationing of care. Within the scope of this study, in addition to the

omission of actions defined in standard operating procedures,[6] task omission was operationally

defined as any reduction of standard conduct. This often includes fundamental nursing tasks directly

related to patient care and safety. Kalisch et al. (2009) reported that 73% of their study’s hospital

nurses omitted interventions and basic care,[8] while 53% of psychosocial care related activities were

left undone.[9] Depending on the cognitive processes of the involved nurses, these activities may be

categorized as missed,[8] left undone,[10] or implicitly rationed;[11] however, all reflect care workers’

partial or total omission of necessary tasks.[8][12]

Factors that influence work performance most noticeably have been reflected in the

literature. Particularly, impaired health has been linked to performance deterioration in numerous

work settings, including healthcare.[13, 14] In this context, the concept of presenteeism has attracted

considerable interest in healthcare research, as it is particularly relevant among healthcare workers.

Presenteeism is the practice of attending work despite illness, which has been demonstrated to

reduce at-work performance.[15][14] Several studies[13, 15, 16] have attributed poor work

performance to ill care workers’ reduced capacities to meet their jobs’ standards of quantity and

quality. In the US, studies of the general population have revealed that common pain (e.g., back

pain) while at work resulted in reduced work performance and loss of productive time.[17] Similarly,

in Switzerland, 25% of the surveyed general population reported decreased work performance due to

back pain;[18] and in the Netherlands, Alavinia et al. (2009) showed a significant association

between self-reported work-related health problems and decreased performance, i.e., work volume

during regular hours, among workers in various occupations.[19] Elsewhere, research on hospital

nurses has demonstrated that musculoskeletal pain negatively influenced work performance.[20] In

long-term care facilities, musculoskeletal pain among nursing personnel compels workers to modify

work tasks or seek extra help from fellow care workers to fulfil their duties.[21] In addition to physical

health, mental health (e.g., depression) could also affect care worker performance[20] by sapping

92

mental and physical energy and hindering concentration.[22] An investigation of their relationships

between physical and mental fatigue and nursing work performance among US registered nurses (in

hospital, community, and nursing home settings) measured their frequency of divergence from

organizational patient safety guidelines, short cuts in patient care, and modification of organizational

standards to accelerate task completion. Findings revealed that the higher the reported fatigue level,

the lower the perceived work performance.[13]

There is consensus that ill direct care providers cannot fully meet their organizations’ work

standards.[20] However, to date, no studies have investigated the relationship between care workers’

health, presenteeism and rationing of nursing care in nursing homes. To address this gap, the

current study’s guiding framework is an adaptation of the WHO Healthy Workplace Model[4] (fig.1),

drawing on the relationship between unhealthy work environments, work-related physical and mental

health stressors, and presenteeism vis-à-vis negative influences on employees’ work performance,

e.g., rationing of care. Previous cross-sectional studies of the Swiss Nursing Homes Human

Resources Project (SHURP) indicated that work environment factors such as perceived staffing

adequacy and leadership were inversely related both to care workers’ health problems[3] and to

presenteeism.[23] Furthermore, high-perceived staffing adequacy functioned as a predictor of lower

rationing of care.[24] Accordingly, utilizing data from the SHURP study and building on previous

findings, this study had two aims: 1) to assess the prevalence of implicit rationing of direct resident

care, including rationing of activities of daily living and of caring, rehabilitation, and monitoring; and 2)

to explore the relationship between care workers’ health and presenteeism regarding implicit

rationing of care

.

93

Figure 1. The WHO framework of “Effects of an Unhealthy Workplace on Employees”

Adapted from Burton (2008) [41]

Unhealthy and unsafe work

environment domains

1-Psychosocial *

2-Physical

3-Personal health resources

4-Entreprise Community involvement

Care workers` health

-Physical

-Mental

Presenteeism

Reduced work performance

1.Implicit rationing of activities of daily living 2. Implicit rationing of caring, monitoring & rehabilitation

1.Ida

mo

da

2.

-P

-M

senteei

*Control variables

94

4.3 Methods


This is a secondary analysis of data from the multi-center cross-sectional Swiss Nursing

Homes Human Resources Project (SHURP). That SHURP study’s sampling and survey methods

are described in detail elsewhere.[25]

The SHURP study included a representative sample of 162 nursing homes across

Switzerland, stratified according to language region, size, and ownership status. Nursing homes with

fewer than 20 beds, residential homes, and geriatric rehabilitation clinics were excluded. Nursing

home care workers of all educational levels, facility administrators and nursing managers were

invited to complete the survey questionnaire. Care workers who worked less than 8 hours weekly,

less than 1 month on the unit, or who were students were excluded. In the parent study, 5,323 care

workers returned questionnaires, resulting in an overall response rate of 76.6%. In the current study,

we included only staff care workers (i.e.. registered nurses, licensed practical nurses, certified

assistant nurses, and nurse aides) directly involved in resident care, and excluded nursing managers

and unit supervisors, resulting in a sub-sample of 3,239 care workers.


Socio-demographic and professional data on care workers, including their perceptions of

their own health and quality of care, were collected using the SHURP study’s Care Worker Personnel

Questionnaire. Nursing home facility characteristics were captured from the SHURP Facility Profile

questionnaire. The SHURP researchers established the content validity of each scale used by testing

the relevance of each variable and scale separately to obtain an item content validity index (I-CVI)

and a scale content validity index (S-CVI), respectively. Further information regarding the survey’s

development and validity pre-testing are described elsewhere [25].

Outcome variables

Implicit rationing of care was measured using the Basel Extent of Rationing of Nursing Care

(BERNCA) instrument, adapted to the nursing home setting.[24] For the SHURP study, three

questions related to rationing of social care activities were added to the original instrument. Items not

relevant to nursing home settings were excluded, leaving the nineteen-item, four-subscale BERNCA–

Nursing Home version. Cronbach’s alphas for the four subscales ranged between 0.76 and 0.94. For

analysis, the mean overall items per subscale was calculated.[24] The current study used two

subscales to describe rationing of nursing activities related to direct resident care: “Implicit rationing

of activities of daily living”, and “Implicit rationing of caring, rehabilitation and monitoring.” The survey

95

question addressed care interventions and therapies that were classed as necessary for specified

residents, but were left unperformed or only partly performed because of lack of time or high

workload over the past seven shifts workers.[11]

The rationing of activities of daily living subscale included 5 direct resident care activities:

sponge bath/skin care; oral or dental hygiene; assistance eating; assistance drinking;

mobilization/changing position. The rationing of caring, rehabilitation, and monitoring subscale

included 8 direct resident care activities: leaving a resident in urine and/or stool longer than 30

minutes; emotional support; necessary conversations with residents and families; toileting and

continence training; activation or rehabilitation activities; monitoring of residents as necessary;

monitoring of cognitively impaired residents, including the application of restraints and sedatives; and

keeping residents waiting following call bells. All items were measured on a 4-point Likert-type scale

(0=never; 1= seldom; 2=sometimes; 3=often), with the further “activity was not necessary” option.[26]

For the rationing of activities of daily living and the rationing of caring, rehabilitation, and monitoring

subscales, internal consistency showed respective Cronbach’s alphas of 0.78 and 0.83 [24].

Explanatory Variables

Three physical health factors were examined, including self-reported back pain, joint pain

and headache. The occurrence of self-reported physical health problems during the 4 weeks prior to

the survey was measured on a 3-point Likert-type scale (1=not at all, 2=a little bit, 3=strongly) using

three items derived from the Swiss Health Survey.[27]

Three self-reported mental health factors were measured: tiredness, sleeplessness, and

work-related emotional exhaustion. Tiredness and sleeplessness over the 4 weeks prior to the

survey were measured on a 3-point Likert-type scale (1=not at all, 2=a little bit, 3=strongly) via two

items derived from the Swiss Health Survey.[27] “Feeling of exhaustion from work” was measured on

a 7-point Likert-type scale (ranging from 0=never, to 6=daily) using a single item from the Maslach

Burnout Inventory (MBI).[28] The validity of single-item emotional exhaustion measurement is

described elsewhere.[29]

For regression analysis, all explanatory variables except emotional exhaustion were

dichotomized as 0=never; 1=a little bit or strongly. Emotional exhaustion was dichotomized as

0=never, several times a year or less, once a month or less; and 1=several times a month, once a

week, several times a week, or daily.

Presenteeism–expressed as the number of days (if any) in the previous four weeks care

workers had attended work in spite of feeling ill and unfit for work–was measured with a single

investigator-developed item.[30, 31] Single-item presenteeism questions are used in studies to

reduce complexity, ambiguity, cost, and respondent burden.[32] Respondents answered by providing

96

a number of days. For later analyses, answers were grouped into three categories (0=0 days; 1=1-2

days; 2=3 or more days) [33].

Control Variables

As control variables, we used care workers’ ages, genders, professional categories (i.e.,

registered nurses, licensed practical nurses, certified nursing assistants, and nurse aides), years’

professional nursing experience (range: 5 years - >20 years), percentage of time employed, i.e.,

≤50%; >50%, (where 42 hours’ working time per week corresponds to 100% employment), and usual

shifts (days, evenings, nights, or regularly rotating shifts). Professional categories were based on

nursing education levels as follows: registered nurses (RNs) (three to four years of education and a

diploma in nursing), licensed practical nurses (LPNs) (three years’ education), certified nursing

assistants (CNA) (two years’ education), and nurse aides (short courses and on-the-job training).

Facility characteristics included nursing home size (range: small (20-49 beds), medium (50-99 beds),

or large (≥100 beds)), language region (German-, French-, or Italian speaking area), and ownership

status (private, private subsidized, or public).

Care worker perceptions regarding their work environment, including leadership and staffing

adequacy, were also used as control variables, as they have been linked closely to their health,[3]

presenteeism,[23] and rationing of care.[24] Two subscales from the Practice Environment Scale of

the Nursing Work Index (PES-NWI) questionnaire were used: “Nurse manager ability, leadership,

and support of care workers” and “Staffing and resource adequacy.”[34] Internal consistency tests of

the two subscales showed Cronbach alphas of 0.84 and 0.74, respectively[24]. The “Nurse manager

ability, leadership, and support of care workers” (Leadership) subscale measured whether

respondents perceived their unit supervisors as supportive and competent leaders, whether mistakes

were used as learning opportunities, and whether care workers received rewards and/or recognition

for work well done, as well as participation in decision-making. “Staffing and resource adequacy”

subscale measured perceptions of whether available staffing levels were sufficient to complete all

necessary work, to provide quality care, and to discuss resident problems. All items were rated on 4-

point Likert-type scales (range: 1 (strongly disagree) - 4 (strongly agree).

4.3.3 Data collection and analysis

The SHURP survey was administered between May 2012 and April 2013. Detailed

information relating to data collection is provided elsewhere.[25]

To address aim 1, we calculated descriptive statistics (frequencies, percentages, means, and

standard deviations). For aim 2, we first analyzed each rationing of care outcome’s bivariate

associations with facility characteristics, care worker characteristics, and work environment factors.

97

We used generalized estimation equation (GEE) multiple regression models to adjust for the

clustering of care workers in nursing home units. Next, for the two self-reported rationing of care

outcome measurements, we used general linear regression models to estimate beta coefficients (β)

and 95% confidence intervals (CI) for physical and mental health status, and presenteeism. We

adjusted for facility and care worker related characteristics, and for work environment factors.

Analysis of missing values showed fewer than 5% of responses missing per variable, with 19.3% of

respondents (n=775) omitting one or more responses. To explore any pattern of omissions, we

analysed the sensitivity of the entire sample (n=4,014) against that of the subgroup who submitted

complete response sets (n=3,239). To compare the means of each variable examined between the

two samples, we calculated Cohen’s d. Calculated differences were small (Cohen’s d<0.2)[33] with

similar inferences. Data analysis was conducted with IBM/SPSS for Mac Statistics 21.0. We report

our analyses’ adjusted results.

4.4 Ethical approval

This study was covered by the SHURP project, for which the Canton of Beider Basel ethics

committee granted approval (Ref. Nr. EK:02/12). Care workers’ voluntary and confidential return of

their questionnaires was treated as informed consent.

4.5 Results


Overall, this study included data on 3,239 care workers in 162 nursing homes. Mean scores

for self-reported rationing of activities of daily living and of caring, rehabilitation and monitoring were

below “seldom” (1.35 and 1.70, respectively). Table 1 summarizes facilities’ characteristics and care

workers’ psychosocial and work related characteristics.

Roughly one-third of participating facilities were state- owned (37.0%), and slightly fewer

than half (46.3%) were medium in size (50-99 beds). Three-quarters (75.9%) were located in

Switzerland’s German-speaking region. A large majority of care workers were female (92.2%); one

third (32.8%) were fifty years of age or older; and 28.1% were registered nurses. The majority

(75.1%) were employed more than fifty percent, and 24.4% had twenty years or more of nursing

experience. Fewer than half (44.8%) reported working mainly day shifts.

Generally, care workers reported physical health complaints ranging from a little bit to

strongly in the previous four weeks. The majority (72.6%) reported back pain; 50.8% reported joint

pain; 66.2% reported tiredness; 47.7% reported sleeplessness; and 45.3% reported headache. More

than a third of respondents (37.7%) reported frequent emotional exhaustion from work, i.e., from

several times a month to daily over the previous four weeks. Of the survey’s 3,239 participating care

98

workers, 26.3% reported presenteeism for at least 2 shifts over the previous month. The mean rating

of the work environment quality was high for leadership (3.13), located just above “rather agree”; for

staffing adequacy the average rating was slightly below “rather agree” (2.81).

99

Table 1. Sample characteristics, (N=3,239)

Facility characteristics n (%) Mean± SD


German

French

Italian

123 (75.9)

30 (18.5)

9 (5.6)

Ownership status

State-owned

Private subsidized

Private

60 (37.0)

43 (26.5)

59 (36.4)

Nursing home size

Small (20-49beds)

Medium (50-99 beds)

Large (≥100 beds)

63 (38.9)

75 (46.3)

24 (14.8)

Care workers` characteristics

Gender

Male

Female

253 (7.8)

2986 (92.2)

Age groups (years)

Up to 30 31-40

41-50

>50

692 (21.4)

590 (18.2)

893 (27.6)

1064 (32.8)

Professional category

Registered nurse

Licensed practical nurse

Certified nursing assistant

Nurse aide

910 (28.1)

799 (24.1)

618 (19.1)

932 (28.8)

Employment percentage

Up to 50%

>50%

805 (24.9)

2434 (75.1)

100

1Back pain, joint pain, tiredness, sleeplessness, headache: 0= never; 1=a little bit, strongly. 2 Emotional exhaustion: 0=never, several times a year or less, once a month or less; 1=several times a month, once a week, several times a week, daily. 3Presenteeism: 0=0 & 1 day; 1=2 & more days. “Group 1” is reported for all variables.

Experience in nursing (years)

Up to 5

6 to 10

11 to 15

16 to 20 >20

667 (20.6)

7481 (23.1)

607 (18.7)

426 (13.2)

791 (24.4)

Usual shift

Days only

Evenings only

Nights only

Regular change of shifts

1450 (44.8)

202 (6.2)

397 (12.3)

1190 (36.7)

Self-reported 1physical and 2mental health status

Back pain

Joint pain

Tiredness

Sleeplessness

Headache

Emotional exhaustion

2350 (72.6)

1647 (50.8)

2144 (66.2)

1544 (47.7)

1466 (45.3)

1220 (37.7)

3 Self-reported presenteeism 851 (26.3)

Work environment factors (scale range 1-4)

Leadership 3.13±0.60

Staffing adequacy 2.81±0.66

Implicit rationing of care outcomes (scale range 0-4)

Activities of daily living

Caring, rehabilitation, & monitoring

1.35±0.54

1.70±0.62

101

4.5.2 Frequency of rationing of care

Overall, rationing of direct resident care activities was rare. On average, for the seven

worked shifts prior to the survey, two-thirds (66.0%) of participants reported never rationing activities

of daily living (Table 2). Most had never rationed assisting in food intake (74.1%) or drinking (77.0%);

strong majorities reported never or rarely rationing bathing (never: 54.6%; seldom: 26.1%) or oral

hygiene (never: 55.4%; seldom: 26.5%).

Concerning activities of caring, rehabilitation and monitoring, over one third (42.7%) reported

“never” rationing care, rehabilitation, and monitoring activities. The great majority had never or

seldom left a resident in urine or stool longer than thirty minutes (never: 68.2%; seldom: 23.4%).

Most also reported either never or seldom rationing emotional support (never: 40.8%, seldom:

34.8%), necessary conversations with residents and families (never: 34.2%; seldom: 34.7%), or

activating/rehabilitating activities (never: 34.2%; seldom: 34.7%)

102

Table 2. Descriptions of implicit rationing of nursing care measures

Self-reported implicit rationing of care (N=3,239) Never (%) Seldom (%) Sometimes

(%)

Often (%) Not necessary

(%)

Rationing of activities of daily living (ADL)

Sponge bath/skin care

Oral hygiene

Assist food intake

Assist drinking

Mobilization/changing position

1768 (54.6)

1795 (55.4)

2401 (74.1)

2494 (77.0)

2238 (69.1)

845 (26.1)

858 (26.5)

427 (13.2)

423 (13.1)

684 (21.1)

402 (12.4)

346 (10.7)

143 (4.4)

168 (5.2)

218 (6.7)

67 (2.1)

70 (2.2)

29 (0.9)

35 (1.1)

33 (1.0)

157 (4.8)

170 (5.2)

239 (7.4)

119 (3.7)

66 (2.0)

Rationing of Caring, rehabilitation, & monitoring

Leave a resident in urine/stool longer than 30mn

Emotional support

Necessary conversation with resident/family

Toileting/continence training

Activation or rehabilitation care

Monitoring of residents as care workers felt necessary

Monitoring of cognitively impaired residents: use of restraints/sedatives

Keeping residents waiting following call bells

2208 (68.2)

1320 (40.8)

1107 (34.2)

1496 (46.2)

1107 (34.2)

1503 (46.4)

1507 (46.5)

808 (24.9)

758 (23.4)

1127 (34.8)

1125 (34.7)

1044 (32.2)

1125 (34.7)

935 (28.9)

852 (26.3)

1297 (40.0)

169 (5.2)

575 (17.8)

586 (18.1)

390 (12.0)

586 (18.1)

496 (15.3)

125 (3.9)

800 (24.7)

28 (0.9)

168 (5.2)

214 (6.6)

85 (2.6)

214 (6.6)

121 (3.7)

125 (3.9)

297 (9.2)

76 (2.3)

49 (1.5)

207 (6.4)

224 (6.9)

207 (6.4)

184 (5.7)

268 (8.3)

37 (1.1)

103

4.5.3 Factors associated with rationing of care

Most of the studied self-reported health factors were positively related to rationing of care

(Table 3). Back pain and sleeplessness did not correlate with rationing of both activities of daily living

and those of caring, rehabilitation, and monitoring. Five other physical and mental health factors were

positively associated with rationing of activities of daily living: joint pain (β 0.04, CI 0.001-0.07);

tiredness (β 0.04; CI 0.002-0.08); headache (β 0.04; CI 0.01-0.08); emotional exhaustion (β 0.11; CI

0.07-0.15), and presenteeism (β 0.05, CI 0.004-0.09).

Similarly, four physical and mental health factors were positively related to rationing of

caring, rehabilitation, and monitoring activities: joint pain (β 0.05, CI 0.01-0.09), tiredness (β 0.07, CI

0.03-0.11), headache (β 0.04, CI 0.001-0.08), and emotional exhaustion (β 0.2, CI 1.16-0.24).

However, no association was shown between presenteeism and rationing of caring, rehabilitation,

and monitoring activities.

.

104

Table 3. Factors related to rationing of care activities, β coefficient (95% CI)

1Explanatory variables

2Implicit rationing of care

Activities of daily living β coefficient 95%(CI)

Caring, rehabilitation & monitoring

β coefficient 95%(CI)

Back pain

0.01 (-0.03-0.04) 0.01 (-0.03-0.05)

Joint pain 0.04 (0.001-0.07)* 0.05 (0.01-0.09)*

Tiredness

0.04 (0.002-0.08)* 0.07 (0.03-0.11)**

Sleeplessness

0.01 (-0.03-0.05) 0.03 (-0.01-0.07)

Headache

0.04 (0.01-0.08)* 0.04 (0.001-0.08)*

Emotional

exhaustion

0.11 (0.07-0.15)** 0.2 (1.16-0.24)**

Presenteeism

0.05 (0.004-0.09)* 0.04 (-0.004-0.09)

1Back pain, joint pain, tiredness, sleeplessness, headache: 0=never; 1=a little bit & strongly. Emotional exhaustion: 0=never, several times a year or less, once a month or less; 1=several times a month, once a week, several times a week, daily. Presenteeism: 0=0 & 1 day; 1=2 and more days. We reported group “1” in comparison to group “0”. 2Models were controlled for facility characteristics (language region, ownership status, size), care worker characteristics (gender, age, professional category, employment percentage, & usual shift work), and work environment factors (perceived leadership & staffing adequacy) *p-value<0.05;**p<0.01

105

4.6 Discussion

This is the first study to explore nursing care workers’ self-reported physical and mental

health issues and presenteeism with regard to rationing of activities of daily living and of caring,

rehabilitation, and monitoring. Although care workers reported some rationing of basic resident care

(e.g., oral care, emotional support, toileting), rationing of care was not common. Results suggested

that workers consistently provided the care vital to residents’ safety (eating, drinking, basic hygiene,

and managing body wastes).[24] After adjustments for care worker characteristics and work

environment factors, further analysis positively related compromised physical and mental health

status, as well as presenteeism, with rationing of care. While the association between presenteeism

and rationing of caring, monitoring, and rehabilitation is not statistically significant, the nearness of

the miss (p=0.07; CI= -0-004-0.09) may warrant further examination. The presented findings strongly

suggest that health and presenteeism are related to care workers’ perceived rationing of care.

In the adjusted models, rationing of care was associated with compromised physical and

mental health, along with presenteeism. Care workers’ joint pain and headache were related to

rationing of activities both of daily living and of caring, rehabilitation, and monitoring. These findings

support those of previous studies[19-21] where musculoskeletal pain was a major contributor to

decreased work performance. As a general observation, by interfering with normal movement, pain

impedes performance of nursing tasks, many of which demand both speed and concentration. Gucer

(2009) reported that reduced work performance was manifested by decreased work volume.[21]

Because neuron activity is closely intertwined with cognitive performance, changes in oxygen

delivery to the cells due to pain perception can impair judgement.[6] Thus, care workers experiencing

pain are more likely to omit residents’ care needs.

One of our findings was that mental health, including tiredness and emotional exhaustion,

was related to rationing of activities both of daily living and of caring, rehabilitation and monitoring.

These findings correspond with those of previous studies linking mental illness to decreased working

capacity.[36] Greater reductions in work performance occurred when mental illness was coupled with

fatigue.[37] When a worker is overwhelmed by a combination of demanding work and physical and

emotional fatigue, withdrawal, i.e., reducing effort and performance, has been observed as a coping

strategy[38]. Furthermore, care workers who experience emotional exhaustion and tiredness have

difficulty focusing their energy and concentration[13] to manage work exigencies. Therefore, as time

pressure builds, they tend to prioritize residents’ immediate safety, physical comfort and wellbeing

(e.g., nutrition and mobilization) above social needs (e.g., communication and support of residents

and families).[24]

Another novel finding was the association of increased presenteeism with increased

rationing of activities of daily living. One study found that hospital and long term facility nurses who

reported compromised health also showed reductions both in working speed and in care quality.[20,

106

39] Work related illness, pain, or exhaustion might explain common incongruities between workers’

knowledge of how to carry out prescribed tasks and their actual fulfilment of those tasks according to

organizational guidelines. By compromising task efficacy and impeding output, impaired health

among care workers ultimately weakens the quality of the care they provide.[39]


SHURP is the first study to assess the relationships between care workers’ health,

presenteeism, and rationing of care in nursing homes. However, related findings should be

interpreted in light of certain limitations. First, the cross-sectional design allows no inference of

causal relationships between the investigated factors and rationing of care. Second, the current

study’s explanatory variables were exclusively self-reported. While care workers’ perceptions of their

own health have been shown reliable[40] they remain a possible source of bias. Finally, as the

frequency of care rationing is reported solely from the care workers’ perspectives, these data might

also be subject to bias.

4.8 Conclusion and Implication for nursing management

This study indicates that nursing home care workers’ health is strongly associated with

rationing of tasks directly related to resident care, i.e., activities of daily living and caring, and of

rehabilitation and monitoring. Therefore, health organizations should be aware of health-related

workplace issues and implement programs to promote and maintain care workers’ health.

Additionally, to reduce rationing of care, administrators should enhance monitoring of emotional

distress and related symptoms. Development and testing of related interventions will require further

observational studies both of care workers’ individual decisions regarding presenteeism and of its

impact on work performance, which may ultimately impact quality of care.

107

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presenteeism. J Occup Environ Med, 2009. 51(11): p. 1256-66.

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with health, work demands, and individual characteristics. Am J Ind Med, 2009. 52(1): p. 49-56.



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110

CHAPTER 5

FACTORS ASSOCIATED WITH JOB SATISFACTION AMONG CARE

WORKERS IN SWISS NURSING HOMES– A CROSS SECTIONAL

STUDY

1René Schwendimann, PhD; 1Suzanne Dhaini; 1,2Dietmar Ausserhofer, PhD; 3Sandra Engberg, PhD; 1Franziska Zuniga, PhD

1Institute of Nursing Sciences, University of Basel, Basel, Switzerland

2Claudiana, University of Applied Science, Bozen – Bolzano (BZ), Italy

3School of Nursing, Pittsburg University, PA, USA

Submitted to the Journal of BMC Nursing, January 2016

111

5.1 Abstract

Background: Nurses’ job satisfaction is related to working conditions and work environment, while it

remains unclear which factors are most influential regarding high job satisfaction in nursing home

settings. The purpose of this study was to describe job satisfaction among care workers in Swiss

nursing homes and to examine associated nursing-related organizational factors and health issues.

Methods: A cross-sectional study using a representative national sample of Swiss nursing homes

including 4145 care workers from all educational levels (registered nurses, licensed practical nurses,

nursing assistants and aides) from 162 nursing homes. Care worker-reported job satisfaction was

measured with a single item; explanatory variables were assessed with established scales, e.g., the

Practice Environment Scale – Nurse Working Index (adapted for nursing home use). Generalized

Estimating Equation (GEE) models were used to examine job satisfaction related factors.

Results: Overall, care workers’ job satisfaction was rather high: 36.2% of respondents reported high

satisfaction with their workplace. Factors significantly associated with high job satisfaction were

supportive leadership (OR= 3.76), improved teamwork and resident safety climate (OR=2.60),

resonant nursing home administrator (OR=2.30), adequate staffing resources (OR=1.40), fewer

workplace conflicts (OR=.61), less sense of depletion after work (OR=.88), and fewer physical health

problems (OR=.91).

Conclusions: The quality of nursing home leadership–at both the unit supervisor and the executive

administrator level–was strongly associated with care workers’ job satisfaction. Therefore,

recruitment strategies addressing specific profiles for nursing home leaders are needed, followed by

ongoing leadership training. Future studies should examine the effects of interventions designed to

improve nursing home leadership and work environments on outcomes both for care staff and for

residents.

112

5.2 Background

Societal and demographic changes are swelling the numbers of care-dependent older people in

long-term care facilities, particularly nursing homes [1, 2]. Decades of hospital-based empirical

studies have linked nurses’ job satisfaction closely to working conditions and work environment, job

stress, role conflict and ambiguity, role perception and content, and organizational and role

commitment [3]. In a recent concept analysis, job satisfaction was defined as “an affective reaction to

a job that results from the incumbent’s comparison of actual outcomes with those that are desired,

expected and deserved” (p 130) [4]. Accordingly, for nurses, it remains a complex phenomenon,

depending on individual feelings, personal expectations and the nature of the job [3].

5.2.1 Literature review

In nursing homes, care workers’ job satisfaction varies considerably between and within countries.

Still, in the US, data from the National Nursing Home Survey indicated that 82% of nursing assistants

were satisfied or extremely satisfied with their jobs [5]; in a similar study in Sweden, 76% of nursing

assistants reported moderate or high general job satisfaction [6]. Other international nursing home

studies report high overall job satisfaction scores among care staff [7, 8], nursing assistants [9], and

registered nurses [10]. Such results suggest that care workers’ job satisfaction is associated with

various work environment factors rather than individual (e.g., age) or facility characteristics (e.g., bed

count) [11]. Higher job satisfaction among nursing home care staff is related to the opportunity to

provide high-quality care [12], effective leadership [13] and teamwork, [14] as well as it is significantly

related to resident satisfaction [15] and person-centered care [6]. Lower job satisfaction correlates

with shortages of qualified personnel [16], inadequate supervision [17], lack of cooperation [18, 17],

health complaints and absence due to illness [19, 20, 6], as well as intent to leave and turnover [21-

23]. At the organizational level, a lack of opportunities for advancement and professional growth as

well as insufficient compensation also appears to contribute strongly to job dissatisfaction [12, 14, 13,

16], while greater job autonomy, job control, and involvement in decision-making [24-28] are all

associated with higher satisfaction.

5.2.2 Nursing homes in the Swiss healthcare system

In the ongoing Swiss Nursing Homes Human Resources Project (SHURP), nursing home

administrators across Switzerland report difficulty recruiting care workers, especially registered

nurses [29]. While the Swiss healthcare system is characterized by a high degree of local autonomy,

all cantons (states) and their municipalities are legally obliged to guarantee primary and ambulatory

care, along with hospitals and long term facilities such as nursing homes [30]. Nursing homes may

have public, private or mixed ownership, and offer services ranging from adult daycare and post-

113

acute care (including rehabilitation) to dementia care and long-term nursing in home-like

environments [29]. In 2012, Switzerland’s 1,558 nursing homes (median size: 59 beds) hosted

121'000 people (mean ages in years: 80.8 (males) and 85.2 (females)) [31]. Nursing home care staff

includes nurses with a broad array of educational levels: formal training and education range from 18

days to 4 years. All home operators must be licensed. Additionally, 11 of the country’s 26 cantons

issue care worker skill mix guidelines. On average, these recommend that 20% of care providers be

tertiary level educated nurses (3-4 years’ education, e.g., registered nurses), and 30% secondary

level educated nurses and healthcare workers (2-3 years’ education). For remaining auxiliary staff,

including nursing aides, no recommendations are given [32].

5.2.3 Literature gap

Although multiple nursing home studies have examined job satisfaction, most focused on no more

than two influencing factors, with no comprehensive exploration either of the multiple nursing-related

organizational factors or of care workers’ health issues–characteristics affecting job satisfaction

across care worker categories–in a representative national nursing home sample. Thus, it remains

unclear which factors are most influential regarding high job satisfaction in nursing home settings.

For the current study, guided by Donabedian’s structure-process-outcome model, [33] we considered

job satisfaction as an outcome determined by organizational factors, along with care worker and work

environment aspects (e.g., leadership, teamwork and safety climate, work stressors) (see figure 1).

114

Figure 1: Nursing home and care worker characteristics and workplace factors related to job satisfaction

Job satisfaction Care worker characteristics –Gender* –Age* –Educational

background* –Physical health –Emotional exhaustion

Work environment –Nurse manager ability,

leadership, and support of nurses (leadership) –Staffing and resources

adequacy (staffing) –Job autonomy –Shared decision making –Advancement opportunities –Collaboration w. higher

management Teamwork and safety climate Work stressors –Conflict and lack of recognition –Workload –Lack of preparation

*Control variables

Facility characteristics –Language region* –Nursing home size* –Profit status*

115

5.3 Methods

5.3.1 Study Aims

1) to determine job satisfaction among Swiss nursing home healthcare workers, and 2) to examine

associated nursing-related organizational factors and care workers’ health issues in a representative

national sample of Swiss nursing homes.

5.3.2 Design and sample

This study utilizes data from the Swiss Nursing Homes Human Resources Project (SHURP), a

cross-sectional multi-center study using 163 randomly sampled officially listed nursing homes across

Switzerland. Facilities were stratified according to language region (German, French, or Italian) and

bed count. Including workers engaged in direct care and employed a minimum of 8 hours per week in

the selected nursing homes resulted in a final sample of 5’323 individuals. The SHURP study’s

sampling and survey methods are described elsewhere in greater detail [34]. The current study

included a national representative sample of nursing homes with at least 20 beds, and excluded

residential homes and hospices. To address our study objectives, we excluded persons with

leadership positions (e.g., unit and department managers), resulting in a study sample of 4,145 care

workers from 162 nursing homes.

5.3.3 Variables and measurement

Outcome variable

Care worker job satisfaction was measured using a single item: “How satisfied are you overall

with your current job in this nursing home?“ Respondents rated their satisfaction on a 4-point Likert-

type scale, ranging from 1 (strongly dissatisfied) to 4 (strongly satisfied). To focus our analysis on the

most satisfied respondents, we dichotomized the outcome variable as follows: 1=strongly satisfied;

2=rather satisfied, rather dissatisfied, or strongly dissatisfied. The single item approach reflects job

satisfaction as a whole with high reliability and validity [35], and has been used successfully in

previous hospital and nursing home studies [36, 15, 5, 37].

Explanatory variables

The independent variables of interest were care workers perceptions of leadership, staffing and

resource adequacy, job autonomy, shared decision making, advancement opportunities, quality of

collaboration with higher management persons, workplace stressors and care workers’ health

complaints. The methods used to measure these variables are described in Table 1.

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Table 1: Description of independent variables used in the job satisfaction study

Variable

Name

Description Measurement

Work environment

Leadership 5-item subscale “Nurse manager ability, leadership, and

support of care workers” of the PES-NWI [48], assessing

support by direct supervisors, their competency, back-up

in decision making, praise and recognition given, and the

use of mistakes as learning opportunities and not criticism

4-point Likert-type

scale from 1=strongly

disagree to 4=strongly

agree

Cronbach’s α=.84

Staffing and

resource

adequacy

3-item subscale “Staffing and resources adequacy” of the

PES-NWI [48], assessing whether there was enough time

and opportunity to discuss resident care problems, enough

qualified personnel to provide quality resident care, and

enough staff to perform all necessary tasks

4-point Likert-type



agree

Cronbach’s α=.74

Job

autonomy

Single item (Investigator developed), assessing whether

care workers decide autonomously how to perform their

work

4-point Likert-type



agree

Shared

decision

making

Single item of the PES-NWI [48], assessing opportunities

for care workers to participate in nursing home policy

decisions (e.g., about resident care or work organization)

Idem

Advancement

opportunities

Single item of the PES-NWI [48], assessing opportunities

for professional advancement (e.g., continuing education

opportunities, special tasks within the team / in the nursing

home)

Idem

Safety Attitude Questionnaire (SAQ)

Teamwork

and safety

climate

Combination of two subscales of the SAQ [49]. Based on

confirmatory factor analysis, the original two subscales for

Teamwork and Safety Climate could not be confirmed.

5-point Likert-type



117

Three items with low item discrimination (corrected item-

scale correlation < 0.4) were removed. This resulted in one

10-item single factor for Teamwork and Safety Climate,

assessing, e.g., the opportunity to speak up or to ask

questions when something is not understood, the extent to

which other team members provide assistance when

needed, the opportunity to discuss errors and to learn from

each other, and the reception of feedback about one’s

performance.

agree with the option

“don’t know”

Cronbach’s α=.89

Quality of collaboration with higher management

Available

director of

nursing

Single item of the PES-NWI [48], assessing whether the

director of nursing is available for the care staff

4-point Likert-type



agree

Resonant

nursing home

administrator

Single item of the PES-NWI [48], assessing whether the

nursing home administrator has an “open ear” and

responds to issues raised by the care staff

Idem

Work stressors - Health Professions Stress Inventory (HPSI)

Of the original 30-item HPSI, [50] 12 items were selected

based on expert ratings concerning their relevance in the

nursing home context. Exploratory factor analysis

identified 3 factors.

5-point Likert-type

scale ranging from

0=never to 4=very

often

Conflict and

lack of

recognition

6-item subscale, assessing, e.g., disagreement with other

health professionals concerning residents’ treatment,

conflicts with supervisors, not being asked about one’s

opinion concerning decisions about one’s job, and not

being paid enough

Idem

Cronbach’s α=.76

Workload 3-item subscale, assessing, e.g., having so much work to

do that not everything can be done well and not having

enough people working to perform the work well

Idem

Cronbach’s α=.74

118

Lack of

preparation

3-item subscale, assessing, e.g., lacking the training to

meet residents’ needs, being afraid of making a mistake in

the residents’ treatment and being overwhelmed by caring

for terminally ill residents

Idem

Cronbach’s α=.63

Health complaints

Physical

health

From the original Swiss Health Survey [51], 5 items on

health complaints, including back pain, joint pain,

tiredness, problems with sleeping, and headache were

extracted to assess care workers’ self-reported physical

health. We combined the 5 items to form a sum index

ranging from 0 to 10 to express care workers general

health condition.

3-point Likert-type

scale from “1=not at

all to 3=strongly”

Cronbach’s α= .70

Depleted

from work

Single item according to the Maslach Burnout Inventory

[52], assessing care workers’ feelings of being depleted at

the end of a working day

7-point Likert-type

scale from "0=never to

6=daily"

119

Care worker characteristics and nursing home characteristics were used as control variables.

Care worker characteristics included age and educational level (registered nurses with diploma or

higher degrees, licensed practical nurses with associate degrees, and nursing assistants/nursing

aides with certified education or informal in-service training). Nursing home characteristics included

facility size (small: 20-49 beds; medium: 50-99 beds; large: ≥100 beds), language region (German-,

French-, or Italian-speaking area) and ownership status (public, private - public subsidized, and

private nursing homes).

5.3.4 Data collection

The SHURP survey was administered from May 2012 until April 2013. All nursing home

administrators gave informed consent for their facilities’ participation and forwarded the

questionnaires and return envelope packages to their care workers. For the care workers, completion

and return of the questionnaire was considered informed consent.

5.3.5 Data Analyses

To fulfill aim 1, care worker and nursing home facility characteristics were analyzed using

descriptive statistics (frequencies, percentages, means and standard deviations). To fulfill aim 2, we

adjusted for skewing of data for job autonomy, shared decision making, advancement opportunities,

and collaboration with higher management by dichotomizing the responses (1=strongly agree/agree;

2=disagree or strongly disagree). To examine factors related to care workers’ job satisfaction (1=

strongly satisfied, 2= rather satisfied, rather dissatisfied, or strongly dissatisfied), we then used

generalized estimating equation (GEE) modeling, accounting for the nestedness of care workers

within facility and unit levels (ICC1 job satisfaction: facility level: 0.07; unit level: 0.10) and controlling

for facility characteristics (size, ownership status, language region) and care worker characteristics

(age, educational levels) in a logistic regression. Our analyses tested both unadjusted and adjusted

models. Multicollinearity among the independent variables (i.e., workplace characteristics and

attributes) was determined with the Variance Inflation Factor (VIF). Accordingly, all variables were

retained because analyzed values remained below the threshold of 5 [38]. The GEE was run with

listwise deletion of missing cases. The analysis was repeated using a GEE model employing multiple

imputation: all variables showed similar significance levels to the first model. A p-level of <.05 was

considered significant. All analyses were performed using IBM© SPSS© Statistics for Windows©,

Version 21.0 software (Armonk, NY: IBM Corp.).

120

5.4 Results

5.4.1 Sample characteristics and care workers’ job satisfaction

The final study sample consisted of 4,145 care workers from 162 nursing home facilities across

Switzerland, with an overall response rate of 76.4%. Respondents came mainly from medium sized

facilities in the German-speaking region. Overall, care workers’ job satisfaction was rather high, with

36.2% reporting strong workplace satisfaction, while 50.4% were rather satisfied and 13.4% were

either rather or strongly dissatisfied. For the work environment characteristics measured, high scores

implied positive perceptions. Similarly, we observed high values for teamwork and safety climate

(3.97) and for leadership (3.13), whereas values were low for workplace conflict related stressors

(.91) and for job preparation (.68). In addition, relatively high proportions of respondents agreed or

strongly agreed with shared decision making options (86.1%), and with directors of nursing being

available for care staff (89.6%). All results related to facility and care worker characteristics are

summarized in Table 2.

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Table 2. Sample characteristics

% Mean SD

Facility characteristics (n =162)

Facility size (number of beds)

Small (<50) 38.9

Medium (50-99) 46.3

Large (≥100) 14.8

Ownership status

Public 37.0

Private, public subsidized 26.5

Private 36.4

Language region

German speaking 75.9

French speaking 18.5

Italian speaking 5.6

Care worker characteristics (n=4,145)

Females (n=4,105) 92.5

Age in years (n=3,750) 42.9 12.3

Educational level (n=4,109)

Registered nurse (3-4 year education) 25.8

Licensed practical nurse (3 year education) 22.1

Certified nurse assistant (1-2 year education) 19.2

Nurse aide (short course, training on the job) 29.6

Other 3.2

Work environment

Leadership (PES-NWI) (1-4), (n=4,145) 3.13 .60

Staffing & resources adequacy (PES-NWI) (1-4), (n=4,138) 2.82 .66

Job autonomy (*), (n=4,117) 80.6

Shared decision making(*), (n=4,123) 86.1

Advancement opportunities (*), (n=4,130) 84.4

122

Teamwork & safety climate (SAQ) (1-5), (n=4,133) 3.97 .66

Conflict and lack of recognition (HPSI) (0-4), (n=4,138) .91 .67

Workload (HPSI) (0-4), (n=4,138) 1.53 .82

Lack of preparation (HPSI) (0-4), (n=4,132) .68 .59

Resonant nursing home administrator (*), (n=4,093) 75.7

Available director of nursing (*), (n=4,114) 89.6

Care worker reported health

Physical health (0-10), (n=4,035) 3.48 2.27

Depleted from work (0-6), (n=4,097) 2.88 1.82

Note: Underlined scores are preferable scores; *dichotomized variables indicate proportion of respondents who

agreed strongly/agreed vs. those who disagreed strongly/disagreed with item, or who rated quality of care as

rather high / very high vs. rather low / very low.

123

5.4.2 Job satisfaction and workplace characteristics

Higher job satisfaction (i.e., strong satisfaction with the workplace) was significantly associated

with half of the examined work environment factors. The strongest association was with leadership:

the odds of high job satisfaction increased almost four-fold with each 1-point increase in leadership

rating (OR= 3.76; 95% CI, 2.83-4.99), in either more than two-fold with a 1-point increase either in

teamwork & resident safety climate (OR= 2.59; 95% CI, 2.02-3.32), or for nursing home

administrators being resonant (as opposed to not listening to care workers) (OR=2.23; 95% CI, 1.67-

2.97). The odds of strong job satisfaction also increased significantly with staffing and resource

adequacy (OR=1.42; 95% CI, 1.17-1.72), and decreased significantly with increases in workplace

conflict (OR= .61; 95% CI, .48-.76), being “depleted from work” (emotional exhaustion) (OR=.88;

95% CI, .83-.93), and physical health issues (OR=.91; 95% CI, .87-.96). For more details see table 3.

124

Table 3: Job satisfaction and nursing home work environment characteristics*

Job satisfaction1 (n=3,750)

OR 95% CI p-value

Leadership (PES-NWI) 3.761 2.833 − 4.993 <0.001

Staffing & resource adequacy (PES-NWI) 1.418 1.166 − 1.724 <0.001

Job autonomy .788 .619 − 1.004 0.054

Shared decision making 1.351 .884 − 2.065 0.164

Advancement opportunities 1.130 .772 − 1.654 0.530

Teamwork & safety climate 2.592 2.021 − 3.323 <0.001

Available director of nursing 1.474 .908 − 2.393 0.117

Resonant nursing home administrator 2.231 1.676 − 2.970 <0.001

Conflict and lack of recognition (HPSI) .605 .483 − .759 <0.001

Workload (HPSI) .863 .737 − 1.011 0.068

Job preparation (HPSI) .995 .829 − 1.193 0.953

Physical health .910 .866 − .955 <0.001

Depleted from work .877 .825− .933 <0.001

Note: Binary logistic regression with GEE. The model was controlled for care worker characteristics (age,

educational level) and facility characteristics (language region, ownership status, and size), OR=Odds ratio,

CI=Confidence interval1 Two groups: 1=strongly satisfied vs. 2=rather satisfied, dissatisfied, or strongly

dissatisfied. Group 1 is reported.

125

5.5 Discussion

To date, this was the most comprehensive study of associations between nursing-related

organizational factors, health-related issues and job satisfaction. Conducted in a representative

national sample of Swiss nursing homes, it revealed that slightly over a third of care workers were

strongly satisfied with their current workplace. Strong job satisfaction was significantly associated

with higher ratings for supportive leadership, teamwork and safety climate, resonant nursing home

administrators, and adequate staffing resources, and with lower ratings for workplace conflict and

health complaints. Other work environment factors, e.g., workload, job autonomy, or director of

nursing being available to the care workers, showed no significant associations with job satisfaction.

The rather high overall job satisfaction ratings of care workers in Swiss nursing homes concur not

only with previous studies’ findings in nursing home [21] and acute-care settings [36], but with those

derived from research in other sectors [39, 40]. However, while all previous studies dichotomized

their data to distinguish positive job satisfaction ratings from negative [15, 21, 5], we focused

exclusively on highly satisfied care workers. By examining this group’s data, we aimed to identify

factors separating average or good nursing home workplaces from those that are excellent.

In our adjusted regression model, three factors most significantly explained variations in the

proportions of care workers reporting strong job satisfaction–nursing home leadership, teamwork and

safety climate and the resonance of the nursing home administrator. In this context, links between

perceptions of supportive leadership–particularly of individual leaders’ types and levels of interaction

with their staff– strongly suggest that workers strongly satisfied with their jobs believe that their

leaders both support them and recognize their input. I.e., supervisors’ support and appreciation are

highly appreciated by highly-satisfied care workers and may contribute to their strong job satisfaction.

These findings agree with those of previous nursing home studies, which have indicated that

supportive managers contribute to nurses` job satisfaction [10, 37]. In addition, as observed

elsewhere, leadership styles that treat care errors as learning opportunities rather than as

opportunities for criticism are more likely to develop trust and commitment among care workers [41,

42]. The high resonance ratings very satisfied workers afford their nursing home administrators imply

that top nursing home leaders foster and maintain direct lines of communication with front line care

workers, monitoring their needs and ensuring the achievement of organizational goals in their daily

operations [43, 44].

As interconnected work environment aspects, enhanced teamwork and safety climate are both

associated with strong job satisfaction, which stabilizes nursing systems at the facility organizational

level. This effect implies that the more stability and equilibrium care workers experience, the more

satisfaction they derive from their current positions [45]. For instance, alongside input from team

members about care activities, constructive performance feedback is highly valued. Furthermore,

both teamwork and safety climate involve support from colleagues in resident care, strengthening

126

care workers’ impressions both that they belong to well-coordinated teams with cultures of mutual

learning and that they would feel safe as patients on their units. As observed in the current study,

confidence in and stimulation from co-workers [12] are related to positive perceptions of teamwork,

fostering high job satisfaction.

Staffing adequacy ratings reflected workers’ personal senses of whether their units’ staff counts

and skill mixes were sufficient to perform all necessary work while maintaining high care quality.

Linked significantly with job satisfaction, this included their opinion of whether they had the time and

the opportunity to discuss resident care problems with one another. However, Van Beek and

colleagues [8] noted that, while their analyses initially indicated significant relationships between

nurse manager reported staffing levels and staff job satisfaction, controlling for communication

density removed the apparent significance of that relationship, i.e., higher staffing alone does not

increase job satisfaction. Instead, where workplace satisfaction is concerned, the current study’s

findings suggest that the effect of allocating a prescribed number of workers to a unit is secondary to

those workers’ perceptions of staffing adequacy (including skill mix) and of their opportunities to

communicate with one another.

The topic of workplace conflict and lack of recognition encompasses a range of stressors with the

potential to impact care workers’ job satisfaction. These include disagreements between care

workers and other health professionals concerning residents’ care, not being asked for input on

decisions related to one’s job (e.g., assignment of residents, task scheduling), clashes with

supervisors, not being permitted to use all one’s skills or being underpaid. Our analyses linked

conflict and lack of recognition significantly with job satisfaction. The subscale used included the item

“not being paid enough,” a factor examined in studies associating nursing assistants’ job satisfaction

strongly with wages and benefits [15, 21]. Additional stressful situations, e.g., work interruptions or

input from non-health professionals on how to do one’s work [46] are not explicitly identified in the

current study. Still, workplace conflict has been shown to impair workers’ productivity, identification

with their team, and job satisfaction [47].

Health issues, e.g., emotional strain (reflected in feelings of emotional exhaustion or depletion at

the end of a working day) and physical symptoms of stress (such as back pain, headache, tiredness

or problems with sleeping) were also inversely associated with strong job satisfaction. Our findings

corroborated those of earlier studies linking low job satisfaction with emotional exhaustion [20] and

physical health complaints [6]. One possible explanation is that physical discomfort and emotional

exhaustion deplete one’s energy, impairing performance, inducing low mood and unpleasant

feelings, and ultimately reducing job satisfaction.

127


The greatest strength of this job satisfaction study among care workers in Swiss nursing homes

was its extensive dataset–the product of a large representative nursing home sample and high

response rates. Additionally, the strict focus on strong job satisfaction responses allowed

identification of the associations most relevant to the nursing home care workforce. However, the

findings should be interpreted with caution in view of its limitations. First, as its cross-sectional design

captures care workers’ job satisfaction and associated factors only at a single instant, no causal

relationships can be inferred. Second, considering the complexity of a socially determined construct

such as job satisfaction, the use of a single item to measure it might be disputable. Nevertheless,

previous studies have successfully applied similar measures to job satisfaction, as well as to related

workplace factors and perceptions [15, 5, 37]. Third, the selection of items examined in relation to job

satisfaction was limited to those used in the SHURP study. Other potentially relevant factors, such as

worker retention or resident outcomes, were left unexamined. Finally, social desirability bias might

have skewed the results towards the positive end, reflecting the workers’ desire to be a member of a

good workplace.

5.7 Conclusions

This study revealed significant associations between strong job satisfaction in Swiss nursing

home care workers and 6 work environment factors: nursing home leadership, teamwork and safety

climate, the resonance of the nursing home administrator, workers’ perceptions of staffing adequacy,

workplace conflict, and health complaints. Of these, the quality of nursing home leadership–at the

levels both of unit supervisor and of executive administrator–figured most prominently in care

workers’ job satisfaction. While this result is supported by various studies of leadership persons’

critical characteristics and behaviors, finding and recruiting the right persons and role models for

leadership positions is a complex task. Clearly, recruitment strategies addressing specific leadership

profiles and skills are necessary, as well as ongoing executive supervision, mentoring and support,

including specific leadership training, particularly for middle management positions. In this cross-

sectional study, a variety of care worker characteristics and organizational factors were examined,

increasing the current understanding of care workers’ job satisfaction. To develop and test the

complex interventions necessary to measure the effects of enhanced nursing home leadership

capacities on residents’ health and quality of care, as well as on care staff outcomes, future

prospective studies are recommended.

128

5.8 Ethics approval

All Swiss cantonal ethics committees approved the SHURP study (leading ethics committee:

Beider Basel, Ref.Nr. EK 02/12).

5.9 Competing interests

The authors declare that they have no competing interests

5.10 Funding

The SHURP study received funds from the Swiss Health Observatory, Nursing Science

Foundation Switzerland, the University of Basel’s Research fund 2012, the Swiss Alzheimer

Association, and an anonymous sponsor. The funding sources were in no way involved in the

collection, analysis, or interpretation of data, or in the writing of this paper.

5.11 Authors’ contributions

RS drafted the manuscript. RS, FZ and DA were involved in the conception and

methodological construct of the study including data analysis and interpretation of data. SE and SD

critically reviewed the manuscript. All authors read and approved the final version of the manuscript.


We deeply appreciate the many contributions of the SHURP research team members and

express our thanks to the participating care workers of the nursing homes for their support. Conflict

of interest: none to declare

129

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CHAPTER 6

SYNTHSIS AND DISCUSSION

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In this final chapter the results of the four studies of this dissertation (Chapter 2 to 5) are

synthesized and key findings are discussed. Furthermore, methodological strengths and limitations of

the dissertation are presented. The last sections of this chapter suggest implications for research and

practice.

6.1 Synthesis of key findings

Using the SHURP care worker survey data, we conducted a series of four observational

studies focussing on care worker health, absenteeism, presenteeism, rationing of care, and job

satisfaction with regard to nursing home work environments.

First, we explored the prevalence of physical and mental health complaints as reported by

care workers, and the relationship of the care workers` perceived health in relation to work

environment aspects. This study revealed a need to improve care workers` safety and wellbeing in

Swiss nursing homes. More precisely, musculoskeletal pain and emotional exhaustion should be

addressed by modelling certain aspects of the work environment (e.g. leadership and staffing

adequacy).

Second, we explored the association between certain work environment aspects (e.g.

perceived leadership and staffing adequacy) and selected care workers` outcomes (absenteeism and

presenteeism), adjusting for major care workers-related organizational variables. The study results

confirmed previous findings on presenteeism but not on absenteeism: in our regression models,

none of our selected work environment explanatory variables was a significant predictor of care

worker-reported absenteeism. However, perceived supportive leadership and staffing adequacy were

significant predictors of presenteeism.

Third, we looked at the relationship between care workers` perceived health and

presenteeism with rationing of care, controlling for previous critical findings on work environment

aspects (leadership and staffing adequacy). Although rationing of care was not reported as a

common occurrence, we observed that it was significantly influenced by perceived physical and

mental health and presenteeism in all regression models.

Fourth, we explored the association of care worker-reported job satisfaction with perceived

work environment aspects and health. Controlling for care worker and organizational variables,

results revealed that health and work environment aspects (e.g. leadership and staffing adequacy) as

perceived by care workers were significant predictors of one`s job satisfaction. This study highlighted

the crucial role of leadership, staffing adequacy, and health in relation to care workers` satisfaction.

Overall, this dissertation adds to the body of knowledge on nursing home care workers`

health the importance of perceived supportive staffing adequacy and leadership in protecting staff

from injuries and emotional stress respectively, and ensuring necessary provision of care according

to nursing standards (e.g. reducing rationing of care). The mechanisms of the relationships found

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between work environment and health, and between health and rationing of care are discussed in the

next section.

6.2 Discussion of key findings

Although not very large, the existing literature examining the effects of organizational factors

and working conditions on nursing home care workers` injuries and emotional health is established.

However, this discussion focuses on specific and critical components of the psychosocial work

environment, e.g. leadership and staffing adequacy, to better evaluate their relative impact on

particular health issues, such as musculoskeletal pain (back pain and joint pain) and emotional

exhaustion. Furthermore, it will discuss a novel finding of the relationships between perceived health

and rationing of necessary resident care, which may have an implication on quality of care.

6.2.1 Perceived staffing adequacy and musculoskeletal pain

A growing number of studies and meta-analytic reviews showed that inadequate staffing can

reduce the quality of patient care [1] and jeopardize patient safety [2]. Despite the mounting evidence

relating inadequate staffing to negative patients` outcomes, little is known about the associations

between inadequate staffing and care workers` health outcomes in nursing homes. Since inadequate

staffing intensifies the physical burden and pace of the care workers` job exigencies, it is only

plausible that it might place nursing home staff at risk for occupational injuries [3] (Chapter 2 and

Chapter 3). Despite the fact that nursing homes are a high-risk workplace not only for residents, but

also for care workers, it is not clear whether inadequate staffing explains the significant reported

prevalence rates of musculoskeletal pain and injuries.

Our findings on the relationship between perceived staffing adequacy and reduced

musculoskeletal pain (back pain and joint pain) conformed to previous nursing home findings [4-6],

where an association between inadequate staffing level and injuries was observed. It is commonly

perceived that nurses who describe understaffing resources, report a high level of mechanical

constraints in movements, postures, and patient handling activities [7]. Having too many patients

and/or not having enough staff to help in the provision of care were reported as one of the hardest

parts of care workers` job [8]. Studies showed that there is a robust association between inadequate

staffing and reported back pain among hospital nurses when adjusting for the amount of time used to

help patients in sitting, standing, walking, lifting and carrying, and pushing and pulling [4]. This

suggests that the complexity of the required tasks in the provision of nursing care plays a role in the

relationship between perceived adequate staffing and the reported rates of musculoskeletal pain and

injuries as it might contribute to work conditions that are conducive to injury [9].

Evidence on the use of mechanical devises to perform lifting and positioning, and their link to

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reduced musculoskeletal injury rates is controversial [10]. Their effectiveness depends on the

willingness of the care worker to invest the time and energy required to use these devices. For this

reason, care workers may decide that the encumbrances associated with using a lifting device

outweigh the benefit in terms of minimizing the risk of injury [9]. This indicates that care workers rely

on each other`s support in performing backbreaking activities. It is sensible that in the case of

perceived inadequate staffing, the instances that care workers move and position their patients

without peer assistance, might carry them to perform strenuous and unsafe postures repeatedly [5].

The lack of the human factor support explains the frustration of care workers and their link of

musculoskeletal problems to inadequate staffing. Typical argument is further supported by

observations from the Magnet-certified hospitals, which are known for their sustainable nursing work

environments in demonstrating that nurses perceive their work environment positively, and report low

rates of occupational health injuries [11].

Of importance, care workers` perception of inadequate staffing is not ideal in reflecting the

actual staffing levels compared to other assessment tools, such as nurse-to-patient ratio from

administrative data [2]. It may be that the absolute number of the care worker, rather than the

qualifications, [9] influences strenuous physical demands, which have been consistently linked to

musculoskeletal problems. As such, measures that capture information about staffing levels, in

addition to those that reflect the adequacy of staffing, may be important in clarifying the issue of

musculoskeletal pain and injuries among care workers. Future studies are necessary to explain the

accuracy and validity of both measuring tools, i.e. the perception staffing adequacy and the actual

nurse-to-patient ratio, in relation to occupational health outcomes.

6.2.2 Perceived leadership and emotional exhaustion

Emotional exhaustion occurs in individuals when their situation is complex and highly

demanding with regard to competence or structural means to deal with the demands [12]. In

healthcare, helping patients with major health problems, although it might be personally rewarding, is

perceived as stressful when patients are not sensible to the efforts made by care workers to assist

them, which was linked to emotional exhaustion [13]. In addition to the responsiveness to patient

emotion, evidence on the relationship between organizational factors and emotional exhaustion

among care workers is well established. Organizational factors include stress-generating work

situations such as increased job demands [14, 15], role conflict [16], low job control [17], and high

workload [15], appear to be major determinants of emotional exhaustion. Furthermore, studies

showed that care workers who experience an inconsistency between efforts spent at work and

expected rewards often report emotional exhaustion [13].

In the prevention of emotional exhaustion, underpinning theories have emphasized the role

of leadership practices [18]. According to Blacke-Mouton theory, it is the leader`s responsibilities to

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focus not only on the work outcome, but also on the human relations within the team [19]. The

dissertation findings (Chapter 2) confirm the link between perceived leadership and self-reported

emotional exhaustion, where perceived supportive leadership and reduction of self-reported

emotional exhaustion were observed [17, 20-22]. Tyrannical leadership practices and too much

control-oriented [23], not enabling other to act [17] significantly predicted emotional exhaustion. It is

common sense that leaders who allow their care workers greater participation in decision making

along with open communication, cultivates a favourable work environment among the team. For the

prevention of emotional exhaustion and subsequent burnout among hospital care workers, the

Regional Development and Mental Health Company in Greece, published a guide indicating efficient

rules of leadership practices [22]. Those rules encourage leaders to consult their team on decisions

that affect them; advise and encourage their staff, help them exercise their tasks, strengthen their

skills, respect and reward their work; assign work tasks equally; show comprehension for their

personal problems; demonstrate respect for their privacy; respect their moral values; avoid gossip;

and enhance a pleasant and decent environment. Obviously, the core of these rules relies on the

creation of a climate of mutual trust [22], as supported by the WHO definition of leadership [24].

Once again, human factor seems to play a key role in promoting health and wellbeing of care

workers. Such findings underscore the pivotal role of leaders in protecting care workers against

emotional exhaustion, and encourage the modification of environmental characteristics, i.e.

leadership practices, in order to alter the undesired care worker outcome, i.e. emotional exhaustion

[21]. Practically, leadership, being an important factor in promoting care workers` health, enhances

the retention of healthy care workers, and ensures subsequent quality care those patients deserve

[20]. Future studies should conduct interventions with longitudinal observations on specific leadership

styles and behaviours in order to clarify critical components of leaders` practice and its impact on

care workers.

6.2.3 Health-and-presenteeism-related rationing of care

In recent clinical and epidemiological research, we observe the use of presenteeism, i.e.

measurement of at work decrements in job performance due to illness, as the newest work outcome

assessment approach [25]. The growing interest in presenteeism stems from the fact that people are

staying longer hours at work [26], and from the unmeasured impact of their physical and mental

health on work performance [25]. Presenteeism is measured by self-report, partly because

parameters such as task performance, or work effort at the individual worker level are increasingly

difficult to collect [25]. Scales that measured on-the-job impact of physical and mental health

problems embrace four dimensions [27], which included time management, physical job tasks,

mental and interpersonal job tasks, and output tasks. The latter accounts for the ability to carry the

workload, achieve quantity and quality standards, and complete work on time [25]. Mental health

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problems such as fatigue [28, 29] and depression [25, 29, 30] as well as headaches [29] were found

associated with a reduction in job performance, irrespective of their severity. In an attempt to explore

the impact of hospital nurse fatigue on work performance measures, Barker (2011) observed that

physical and emotional fatigue are associated short-cuts in patient care and non-compliance with

existing organizational standards for safe patient handling [28].

Implicit rationing of care, omission of care, or missed care, three different conceptual

definitions and operationalization [31] referring to any aspect of essential patient care that is omitted

(either in part or in whole) or delayed [32]. Studies have observed that communication breakdown

and patients` workload [32], inadequate staffing, and time pressure can result in withholding partially

or fully necessary nursing tasks [31, 33]. One of this dissertation`s key findings, is the connection

between compromised physical and mental health and self-reported rationing of care (Chapter 4). To

the best of our knowledge, this is the first study that explores the impact of care workers perceived

health and presenteeism on rationing of care by proxy, in nursing homes. The findings of this study

revealed a possible inconsistency relative to the nursing practice. While care workers are taught

appropriate nursing standards of care in their basic nursing education and training, and reinforced by

policies and procedures at the workplace [32], they continue to report rationing of necessary care. A

plausible explanation to this association is that pain and health limitations come in the way of fulfilling

adequate and necessary care to residents. Unfortunately, when care workers do not fulfill their tasks

as per professional practice standards, they often report distress and job dissatisfaction [32]. In this

case, the critical impacting element is compromised health. Negative job experiences, such as job

dissatisfaction, can provoke the care worker to leave the organization, and worsening staff shortage.

Additionally, the act of rationing necessary care is considered a patient error [32], which may lead to

an adverse patient outcome [34, 35]. In light of this finding, it is imperative to deal with rationing of

care as a correlate of quality of care [36], due to its potential negative consequences on both, care

workers and residents.

This dissertation has contributed to the existing body of knowledge on organizational

determinants of implicit rationing of care [31-33, 36], the impact of perceived health and

presenteeism. Our findings confirmed that perceived health and attending to work despite illness

influence care workers` job performance by increasing the odds of implicit rationing of care.

However, underscoring the study findings does not do justice to the depth of the problem. Nurse

managers and leaders need to inquire about the impact of care workers` compromised health and

presenteeism on the provision of necessary care. Individuals with physical and mental health issues

might benefit from work-focused interventions [37] to address barriers to effective job performance

and reduce rationing of care. Furthermore, they may learn new approaches in time management,

work output, and physical tasks in order to manage their job demands [37]. The results reported here

are limited by the fact that assessment of rationing of care and presenteeism is based on self-reports

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and single item measure, respectively. Thus, future studies are required to perform objective

assessments and collect independent data measures in relation to rationing of care, and use validate

existing scale in the measure of presenteeism. Moreover, other measures than rationing of care are

needed in order to elucidate the relationship between compromised health, presenteeism, and job

performance in healthcare, especially nursing homes.

6.3 Theoretical background, conceptualization and measurements of care workers` health

Our findings raise questions on the underlying assumptions of how work environment

aspects (e.g. leadership and adequate staffing) promotes care workers` health and wellbeing. To

date, no theoretical model has explored (1) how care workers` health is related to care worker

professional (e.g. presenteeism) and clinical performance outcomes (e.g. rationing of care) and (2)

how work environments can be modified, accordingly.

Due to lack of existing models that guide occupational health and safety research, we

selected the World Health Organization Model for Healthy Workplace based on the following criteria:

(1) comprehensive and covering the key areas that shape the workplace, (2) simple, avoiding

complex scientific constructs hard to operationalize, (3) useful in providing guidance for program

development in promoting healthy workplaces, and (4) can be used by policy makers and

practitioners. In light of the empirical findings described in the four sub-studies (Chapter 2 to

Chapter 5), along with scarcity in occupational health models, critical reflections on theory will be

necessary regarding the conceptualization and measurement of care workers` health, its

determinants, and its outcomes. Our three sub-studies (Chapter 2, Chapter 3, and Chapter 4)

supported the model hypothesis where a relationship between care workers` health and various work

environment aspects –although not causal- was found; our results confirm its proximity to nursing

outcomes. However, the model provides neither a clear definition of care worker productivity and job

performance (Chapter 4), nor descriptions of how to measure care worker-related constructs in

healthcare organizations (Chapter 4 and chapter 5).

International evidence showed the existence of various conceptualization models to guide

health research in quality of care and patient safety (e.g. Donabedian’s Structure, Process, Outcome

Model, Vincent’s Accident causation Model, Meikirch Model) [38-41], but not one standard model

tailored to care workers` occupational health and safety. The Meikirch model is tailored to the

population health (e.g. patients), and does not describe the operationalization of its determinants.

Hence, the application of this model to explore nursing outcomes (e.g. presenteeism, job satisfaction,

and rationing of care) can be challenging. Furthermore, the Donabedian Model focusing on the

quality of care, and the Vincent`s Model concentrating on patient safety, both provided limited

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description of either the structure or the processes regarding care workers health respectively, and

no guidance for system aspects modeling and improvement strategies were provided [40].

In 1946, the preamble of the World Health Organization`s (WHO) constitution defined health

as a state of “complete physical, mental, and social wellbeing and not merely the absence of disease

or infirmity” [38]. However, the focus of public policy has shifted considerably in the past two

decades. From a strict definition of occupational safety and health that is concerned merely with the

prevention of occupational injuries and illnesses, it is now moving towards a more encompassing

concept geared towards the overall protection of workers’ health, the maintenance of their working

capacity and the improvement of the working environment in a manner that promotes and sustain a

safer and healthier workplaces [39]. Promoting the health of individuals is a complex endeavor as it is

dependent upon individuals, communities, governments, health professionals, administrators, and

others whose activities interweave [38]. More recent, the Meikirch Model on population health [38]

posits that health “is a state of well-being emergent from conductive interactions between individuals

`potentials, life`s demands, and social and environmental determinants”. These determinants interact

and modify both the demands of life and the individuals` potentials to respond satisfactorily to these

demands. There is an established link between the environment, development, and health [42]. The

shared understanding of inaugurating an appropriate and enabling environment that ensures and

promotes health supports the ongoing efforts (e.g. WHO definition of health) to contribute to the

individual`s health [38].

The lack of either a solid theoretical grounding or a conceptual framework in occupational

health continues to impede the measurement and operationalization of care workers` health, its

determinants and its outcomes. To date, some agreement exists between researchers that one`s

surrounding influences the overall health [38]. Overcoming the limitations of existing models used in

healthcare research (e.g. Donabedian` s, Vincent` s, and Meikirch` s), the WHO model has both

explanatory and predictive power in depicting and modeling unhealthy workplaces. The conceptual

strength of our proposed model lies in its clear constructs of interest and why they relate to each

other in the way they were proposed [43]. It is central for providing a view of the whole influencing

domains instead of focusing on only one aspect of the work environment, and treating that aspect in

isolation. It characterizes the interaction between care workers and their work environment in a

comprehensive and coherent manner, where identification of hazards and interventions can be easily

determined. Furthermore, it defines if a change in one factor in the workplace leads to specific

outcomes. It proposes clear boundaries for the constructs of workplace hazards, which would

alleviate the dilemma that results from multiple and conceptually overlapping measures [43].

Moreover, the model demonstrates the existence of a relationship between independent and

dependent variables [43], in this case, the hypothesized relationship between unhealthy workplaces

and compromised physical and mental health. One disadvantage of this approach is that it does not

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address the interventions that policy makers and local authorities should take to influence the health

of care workers. As a result, examples of effective or ineffective interventions were not mentioned in

the description of the model [44].

6.4 Strengths and limitations of methods

Using cross-sectional care worker survey data, this dissertation thesis is embedded in the

Swiss Nursing Home Human Resource Project (SHURP) -the largest nursing home outcome study

conducted to date in Switzerland. The methodological strengths and limitations of such a dissertation

project depend on the method used in the parent study. Therefore, the strengths and limitations of

this dissertation project have to be viewed in light of its relationship to the SHURP study protocol

[45].

SHURP used a cross-sectional study design and observational research methods. Using

typical study designs provide a glimpse of the organizational behaviour at a particular point in time.

Therefore, as it follows no chronological interactions, no cause and effect relationship can be

confirmed or refuted. Although the development of this dissertation`s aims were guided by a

conceptual model, the results of correlation and regression analysis, such as the relationship

between care workers` perceived health and other organizational variables and nursing outcomes do

not allow causal interpretation.

Another factor to consider is avoiding systematic measuring errors in relation to data

collection, specifically common method variance [46]. Correlations between items measured using

the same method can be a source of behavioural research bias [46]. Recommendations have been

made to overcome common method variance. In this study, to avoid the burden of participants to

respond according to social expectations, confidentiality was communicated and guaranteed to all

participants. Furthermore, all constructs were clearly separated with respect to the content using

separate Likert-type scales.

SHURP collected data on important care worker-related organizational factors relating to

nursing outcomes and resident safety from a nation-wide Swiss nursing home sample. SHURP

included a stratified random sampling procedure for nursing home facilities considering language

region and facility size. Our sample included 163 nursing homes from all three Swiss language

regions (German, French, and Italian) and nursing home sizes (small <50 beds, medium 50-99 beds,

and large >100 beds), allowing us to compare findings across nursing home facilities on a national

level. However, based on the SHURP study protocol [45], we only included formally acknowledged

nursing homes with a capacity of at least 20 beds and 15 care workers, respectively. Retirement

homes and assisted living facilities were not included. Given these inclusion criteria, facilities with a

small number of resident beds (< 20 beds) and direct care providers (<15 care workers) were

underrepresented in relation to their portion to the total nursing home population, which increases the

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risk for sample selection bias. Hence, we are not sure if our findings can be transferred to these

smaller facilities. Moreover, in quantitative research, the question remains on whether its results are

generalizable to other settings and international contexts. In fact, the selection of a representative

sample of the nursing home population using a random method strategy enables statistical

generalisation [47].

The large overall sample size of care workers (N=5,323) was a strength for this dissertation,

because it ensured enough power to detect meaningful differences [48] and statistically significant

results [49]. It also helped estimating the precision that the study will yield, and combat uncertainty

[48]. Equally important, the large sample size is essential in interpreting the relevance of findings with

regard to the sample itself [48]. The overall high questionnaire response rate (76%) allowed robust

data analyses on critical care worker-related organizational aspects, including perceived physical and

mental health status. High response rates are an indication of a nonresponse bias, accuracy and

reliability of survey data [49]. At the level of interest (e.g. facility or unit level), a response rate of 76%

shows high consistency of response, which justifies aggregation of care workers` responses at the

unit level [50].

Finally, this dissertation relied solely on care workers perception of work environment in the

analysis of outcome measures (health, presenteeism, absenteeism, rationing of care, and job

satisfaction). As care workers were asked to report whether they suffered from physical and mental

health problems in the past four weeks prior to the survey, difficulties in relating non-work related

health issues and chronic illnesses to work conditions might have contributed to bias, affecting the

reliability and validity of our outcome measures. In Switzerland, national data registries (e.g. SUVA

Insurance Plus) exist for compensation claims regarding occupational injuries and illnesses

(musculoskeletal injuries, emotional exhaustion, and burnout), which can be used to better validation

of outcome measures. While we acknowledge that care workers` report represent a major limitation

of this dissertation, as we were not able to validate those reports, evidence has supported self-rated

health in predicting health incidents and pain [51].

6.5 Implications for practice

The growing demand for long-term care services and the pressure to provide adequate and

high quality of care to residents, protecting them from harm related to the provision of care, put

nursing homes even more under pressure to assure a safe and healthy workplace for care workers.

Creating a safe work environment demands a broad range of activities. With regard to physical

health, it is important for care workers and nursing administrators to learn about environmental

factors that contribute to musculoskeletal pain and to assist care workers in avoiding back and joint

injuries by advocating for safer lifting, handling, and patient movement practice, anchored by a team

of work, especially for those working in nursing homes. International agencies` initiatives, such as the

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European Agency for Safety and Health at Work (EU-OSHA) [52, 53] and the Occupational Safety

and Health Administration (OSHA) in the U.S. [54] obliged health organizational leaders to take

preventive and appropriate measures to make the workplace healthier and safer. For example, the

EU-OSHA [52] introduced the principle of risk assessment as a key element and defined its main

elements as part of the general management process (e.g. hazard identification, including

psychosocial risk hazards [53], worker participation, and introduction of adequate measures with the

priority of eliminating risk at source). In the same line, the OSHA introduced strict guidelines for the

prevention of musculoskeletal injuries in nursing homes [54]. Additionally, when adequate human

resources and assistance are provided for the required physical constraints, the care worker will not

be put in a position of non-compliance with the organization standards and safety procedures [8]. For

care workers reporting compromised mental health, specific intervention programs need to be

designed to help reduce emotional exhaustion and other related symptoms (e.g. tiredness). The

provision of proper care and support for individuals experiencing work-related health issues is both

an ethical and a wise business decision [8]. These individuals may reduce their intention to leave,

lower turnover rates [55], which are important factors in continuity of care and, ultimately, improve

resident outcomes [8]. Although methods (e.g. training) and tools (e.g. ergonomic equipment) might

help, our findings stress human factors to have the impact on both physical and mental health in the

work environment: poor leadership, staffing inadequacy, and conflict and lack of recognition. Senior

leadership accountability is a key factor for promoting and sustaining a facility-wide safety for its staff,

improving working relationships within and across teams, and facilitating two-way communication.

When guidelines are amended, and nursing home facilities offer more and consistent assistance to

their care workers, reported compromised health decline [8]. Engaged nursing home facilities and

unit leaders can drive improvement in the workplace by designing strategies that guide safe working

process and outcomes. Information and education on protective psychosocial work environment

factors are an important aspect in this regard. However, unless leaders in the work environment

provide enough staff qualified to support the enactment of safe work practices that they are

disseminating to their staff, these efforts may go unsuccessful. Another key element of many

effective interventions is job design, either through a micro-ergonomic approach (i.e. reducing

workload), or through a macro-ergonomic approach (i.e. job redesign and organizational change)

[16]. Leaders can help maintain a balance by regulating the number of demands placed on the care

worker, both in terms of workload and redesigning jobs to remove unnecessary tasks [16]. Seeking

their input and feedback in job redesign, care workers will feel greater involvement in decision

making and better communication exchange [16].

Furthermore, recognizing the influence of health and presenteeism on job performance,

including rationing of care, healthcare leaders should consider interventions that increase the

possibilities for care workers with compromised health to either stay home or allow working according

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to their abilities [56]. The availability of unconditional paid sick leave is a first step in limiting the

impact of presenteeism. Managers should reinforce the availability of unrestricted paid sick leave and

systematic processes for screening care workers who report or demonstrate any type of illness.

These noted strategies can be a real opportunity to promote resident safety [57]. In light of the

impacts of health and presenteeism, and on the path to high accountability and reliability, nursing

home leaders need to develop and implement comprehensive and measurable models that assess

and evaluate care workers` job performance in relation to working while ill, following the standards of

care. Although the complex relationship between rationing of care due to illness and quality of care

has not been explored to date, assessing aspects of job performance can be beneficial for resident

safety [58]. This opportunity offers increased awareness of care workers about resident safety and

safe practices. Nursing homes` assessments and evaluations can be compared across units and

facilities in order to perform benchmarking and comparisons. Typical data help underscoring not only

rationing of care, but also several other aspects of job performance, to allow specific interventions

tailored to needs. Engaged facilities in the safety and wellbeing of their care workers foster even

more job satisfaction and reduction of turn over. It is hence important that leaders and care workers

are informed via appropriate indicators of the determinants and impacts of health and safety, which

paint a picture of the state of the workplace infrastructure, [39].

6.6 Implications for future research

Despite the contribution of this dissertation, further analysis is needed to deepen our

understanding of the relationships between care worker-reported health, organizational system

variables, job performance, and quality of resident care. In an era when it’s imperative that all

possible avenues for improving the quality of care and decreasing health care costs be explored [58],

we hope that the results of the four sub-studies of this dissertation will be a stepping-stone to prompt

further investigation.

First, the associations between care workers perceived health and major organizational

variables in Swiss nursing homes should be retested using more reliable outcome measures,

preferably data from objective assessments of care workers health, including formal work-related sick

leaves, physical exams, compensation claims, and incident reports on injuries and accidents. Such

analyses would add to evidence on work environment-related health by providing stronger evidence

on relationships with other variables. Second we need to expand our knowledge both of how health

and presenteeism are related to job performance aspects, in addition to rationing of care, and how

these factors affect resident safety and quality of care. To date, studies on presenteeism, including

this dissertation, have looked too narrowly at this behavior and its implications on job performance

measures. The Stanford Presenteeism Scale [59] serves as a useful assessment tool on worker

health and performance. It captures two dimensions of presenteeism, including the focus on work

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process (i.e. one`s ability to focus on work without being distracted by health problems) and work

outcome (i.e. completing work). Using this scale, future studies are recommended to test association

of presenteeism with resident outcomes and quality of care.

Studies need to move beyond the tendency to use observational designs. The use of

moderators and mediators, rather than isolated regression analysis, helps clarifying relationships

between various constructs and advances knowledge on resident safety and high quality of care in

relation to staff presenteeism. Additionally, intervention studies, aiming at ultimately improving

resident quality of care, would further contribute to the nursing home work environment and care

workers` health. Incorporating a range of individual and organizational interventions may create a

healthy and safe work environment as well as behavior change. So far, the evaluation of workplace

health interventions is somewhat limited [44]. In view of that, the WHO conceptual model might

provide guidance for testing indirect effect between organizational variables-related health and

presenteeism (e.g. psychosocial work environment), job performance measures (e.g. rationing of

care), and resident outcomes. It can also provide a useful support for program development and

implementation.

Taking an international perspective, a much stronger investigation of presenteeism and job

performance aspects (i.e. rationing of care) is needed to improve our understanding of these two

concepts in nursing homes, and to develop an integrative framework on how, and in what area,

working despite illness affect job performance, and ultimately, quality of care. The Work Limitation

Questionnaire is a reliable and valid self-report instrument for measuring the degree to which health

problems interfere with ability to perform job exigencies [27]. The above-mentioned questionnaire is

context driven and focuses on job requirement performance, which can be applied in the nursing

home setting to identify the magnitude and type of deficit that health problems are having in the

workplace [27]. To complement this research topic, qualitative studies can be of use to develop

stronger theoretical base for the concepts of both presenteeism and job performance, as well as for

quality of care. Focused interviews could be an approach to discuss care workers` perceptions of

their at-work performance during illness, and how they rate quality of care accordingly, in order to

develop common understandings relevant to these concepts. The overall aim is to develop indicators

for job performance in relation to quality of care pertinent to the nursing home setting.

6.7 Conclusions

Adding to the record of science development and benefits to the healthcare field, SHURP

has contributed to care workers` health in exploring its determinants and outcomes in the nursing

home setting. Compromised health, such as back pain, joint pain, tiredness, sleeplessness,

headache, and emotional exhaustion are commonly reported among care workers. Typical for a high

risk work setting like the nursing home, sustaining a healthy work environment to promote care

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workers` health and wellbeing, necessitates an anticipatory approach to overcome deficiencies in the

psychosocial work environment system. Investigating care workers` perceptions on measurable work

environment factors reflecting the level of workplace safety, can help detecting problematic system

conditions in terms of human factors related to perceived health and subsequent outcomes.

This dissertation adds to the existing body of knowledge, offering a comprehensive view of

the effect the work environment on care workers health, and of health on rationing of care, and job

satisfaction. Our findings confirmed the underlying theoretical assumption that safe work

environments are related to healthy care workers, and subsequent better job performance. Although

our results suggested that care workers` health, especially back pain and emotional exhaustion, is of

concern in many Swiss nursing home facilities, and the need for promotion and improvement, it

remains less clear how would sustaining the health of care workers improve quality of care in relation

to job performance (e.g. reducing rationing of care). While contributing further to the knowledge of

care workers` health in nursing homes, and the influential aspects of the work environment, this

dissertation thesis raises methodological issues that warrant further attention in future studies.

147

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THE SIGNIFICANCE OF THE PSYCHOSOCIAL WORK … Publication... · 2016-05-25 · the significance of the psychosocial work environment for care workers`perceived health, presenteeism,